PERSONALIZED CARE PLAN TOOL The Individual Service Plan (ISP) is a comprehensive, personalized, detailed road map on how to provide care and services to a particular resident that will result in successful outcomes for both the team members and the resident. This plan will engage the resident's functional, psychosocial and cognitive abilities.
Functional Capabilities GROOMING • What products do they prefer (favorite brand of soap, shampoo)? • Do makeup or shaving items need to be unlocked and set up? Does the resident have access to his/her grooming products? • Do they require assistance with combing hair? How much? • Do they need cueing? Are they able to complete on their own with a few verbal cues? Relay that in the instructions to the care team.
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DENTAL • Does the resident need help with putting toothpaste on toothbrush? • Does the resident have a routine surrounding denture care? • How many times do they brush their teeth a day (e.g., after all meals, once in the morning and once at bedtime)? Indicate that in the instructions to the care team.
BATHING • State what type of assistance is needed for this resident. Be mindful of remaining abilities. • Be clear: If the resident needs assistance with the lower body but can wash the upper body, state that. • Does resident need help with getting into the shower? Is a shower chair present? • Remind the care staff to check for comfortable water temperatures and to have bath towels and supplies ready and available. • Does this resident have any fears surrounding bathing? What do we know works if the resident is resistant to showers? State that for the care team.
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BATHING EXAMPLE Care partner to prepare the environment with towels and a caddy with fresh, clean washcloths, favorite soap and shampoo. Ensure the water is set to a comfortable temperature before assisting resident into the shower. Be sure to state what you are going to assist with, and ask the resident if it is okay to proceed. Assist the resident into the shower. (Seated on a shower chair, if necessary.) Resident prefers to use Softsoap brand to wash her body. Add soap to a warm washcloth and cue the resident to wash her arms and upper torso. Rinse the cloth and apply additional soap. Cue the resident to wash under the right arm, rinse the cloth. Repeat for the left underarm. Use a clean cloth to assist the resident with washing her back. Rinse the cloth, apply additional soap and wash the resident’s legs and then feet. Ensure you wash between the toes and bottoms of feet. Give the resident a warm, wet washcloth lathered with soap and cue the resident to wash her peri area. If resident needs additional assistance, ask for permission to assist and state that you are going to assist in washing and rinsing her peri area. Ask the resident if you may wash her hair. Check temperature to ensure the resident is comfortable and warm. Wet the resident’s hair and lather with her favorite shampoo – Suave.
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Comfort the resident during the showering process if she shows signs of distress. Ensure she is warm and comfortable. Once the shower is complete, drape the resident with a towel over shoulders and a smaller towel over head to keep her warm and comfortable. Dry the resident’s body starting with her legs and feet. Cue the resident to assist with drying her upper body. Be sure to dry in between each toe and any creases in skin. Assist the resident gently from the shower, keeping a towel draped over her shoulders. Ask the resident to assist with applying lotion to her upper body. Ask if you can apply lotion to her legs and feet. Proceed to the dressing process. Care team to notify the MCD and HWD if there is a decline or change in this resident’s ability to assist with the bathing process.
DRESSING • • •
What type of dressing assistance does this resident need? Cueing only? Partial assistance? Selection of clothing? If resident needs assistance with clothing choices, indicate to the care team what that looks like. If resident needs full assistance with dressing, remind the care aide to offer choices in the instructions. If resident has a favorite sweater or pair of shoes she wears daily, indicate that on the care plan.
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DRESSING EXAMPLE Resident may have days where additional support is needed with dressing and choosing clothing. Care partner to choose two different blouses and ask the resident what blouse she prefers to wear today. Repeat with pants and sweaters. Ask the resident if she would like to accessorize her outfit with any additional pieces, such as jewelry or scarves. Resident has always taken great pride in her appearance, and fashion was a big part of her life. Care partner to ask resident if she needs assistance with buttons or zippers. Allow the resident to assist where able. Report any decline in abilities with this ADL to MCD.
SLEEP HABITS • What should the care team know concerning the resident’s sleep habits? • Does the resident wander at night? If the resident is up at night, what interventions are in place for that resident? • Does the care team need specific direction? Are there particular programming or engagement interventions in place?
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SLEEP HABITS EXAMPLE Resident may wander at night, oftentimes feeling sad and missing family. Care partner to put on the resident’s favorite CD, Patsy Cline, low volume. Be sure to give the resident her lifelike, robotic cat, Sam, along with a warm blanket. Care partner to sit in the chair next to the resident’s bed for a few moments until she feels safe and relaxed enough to go back to sleep.
NIGHTTIME CARE • Give the care aide specific instructions on why checks are necessary for the resident. • Add the time frame for when the checks should be completed on the night shift. • Inform the care team to note any incidents in the 24-hour report. • Report any changes, declining sleep patterns or atypical behaviors to the night nurse, MCD and HWD.
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DIETARY • Add any special diets to the instructions for this portion. Restrictions for allergies? • Add the resident’s favorite foods here or any foods they are averse to. Share as much information with the care team as possible.
DIETARY EXAMPLE Resident’s favorite foods include asparagus, grilled chicken, red meats and potatoes. She enjoys anything chocolate and always drinks a Diet Coke with her dinner. Resident has always completed her dinner with a small dish of chocolate ice cream for as long as her family can remember. Care aide to ask the resident if she would like her usual bowl of ice cream or if she prefers what is on the menu for dessert that day.
EATING • Add details for the dining process so the care team knows how to proceed. Is there a particular table the resident likes to sit at? • Does the resident need assistance with cutting up her food? Does the care team member need to sit with this resident to stimulate conversation to 7 help encourage eating and maintaining good nutrition?
• Are there circumstances in the dining room the care team needs to be aware of when seating and serving the resident? Indicate that in the instructions on the care plan for this portion.
TRAY EATING • If tray service is requested by a resident in memory care, please state in the instructions to the care team that a staff member will need to sit with the resident while they eat their meal, especially in situations with swallowing issues.
VISION • Inform the care team member of any details concerning glasses if the resident wears them. Is there a particular location the aide would find them in or need to place them at night? Are they kept on a med cart for safe keeping? • Are they to be kept in a locked cabinet at night?
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HEARING • Inform the care team member of any details concerning the hearing aids if the resident wears them. Is there a particular location the aide would find them in or need to place them at night? Are they kept on a med cart for safekeeping? • Are they to be kept in a locked cabinet at night?
SPEECH/COMMUNICATION • Add details surrounding communication. What support does the resident need from care staff? • Extra time? • Flash cards? Is aphasia present? • Are there particular ways a resident prefers to be approached? Are they agitated easily by loud noises? State these details for the care aide performing care in this section to provide additional support to the team on communicating effectively with the resident.
TOILETING • Give the care aide details surrounding the toileting processes for the resident.
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• What is the resident able to assist with? Are they continent in the day and need products and support at night? • Is a toilet schedule in place for specific behaviors? Give the care aides needed information in order to provide optimal care and support to the resident surrounding this vulnerable task in supporting those needing assistance.
TOILETING EXAMPLE Care partner to remind the resident every 1.5 hours or as needed to use the bathroom to avoid incontinence episodes. At times, resident may mistake chairs or other pieces of furniture for a toilet. To assist in supporting resident, care partner will keep the resident’s door unlocked at all times so she may access her apartment if she is looking for a bathroom. On her bathroom door, a sign displaying the term “Ladies Room” along with a universal symbol indicating a bathroom is placed. Providing visual cues may help increase this resident’s ability and ease in finding a bathroom. Care partner to remain patient with resident and offer her opportunities to use the toilet in the appropriate places. If the resident has an accident, be sure to help the resident avoid feelings of shame by comforting her and ensuring you are there to help her.
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STABILITY • How many falls has the resident had? What are the details surrounding the falls? • What are the interventions for the falls? They may include clinical interventions, or programming or engagement interventions. List those for the care team so they are aware of what to provide to add support.
STABILITY EXAMPLE Resident has had three falls since last assessment. Care aide to provide reminders to use walker as often as possible to avoid falls. Care aide to escort resident to gardening club directly after morning exercise to assist in navigating the outdoor walkway. Keeping the resident engaged in programs throughout the day where there is additional support with staff to assist resident when she may forget her walker reduces the opportunity for falls. Resident enjoys social gatherings, bingo, gardening club and knitting clubs. Care aide to ensure resident is reminded and invited to participate in these programs throughout the day. Care aide will review daily offerings in the daily huddles with MCD and team.
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TRANSFER ABILITY • • • •
Add details for transfer ability for the care aide. Does the resident need additional time to transfer? Assistance? X1 person? Does a walker need positioned nearby? Remind the team to ask permission to assist and inform the resident of what that assistance would look like.
ESCORTING • Be specific to the care aide about what places in the community the resident needs escorting. Beauty salon? Dining room for each meal? • Does the resident need specific reminders for particular programs? • List any programming the resident takes part in regularly and will need escorting to.
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ASSISTIVE/ADAPTIVE DEVICES • List any adaptive equipment the resident uses, such as a walker. • Provide reminders to the care aide in the instruction box regarding support to the resident with adaptive equipment. • Example: “The care aide will need to provide frequent reminders to the resident to use her walker as she often forgets to take it with her.”
SAFETY/EVACUATION • Do you need to provide an Individual Evacuation Plan? State what type of assistance is needed during an evacuation for the resident.
SAFETY/EVACUATION EXAMPLE Resident will need additional time and assistance to evacuate the building during an emergency. Resident uses a wheeled walker and moves at a slow pace. She has some hearing disadvantages and may not hear alarms from her apartment with the door closed.
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Care aide on assignment A will be responsible for assisting resident to the evacuation point. Care aide will need to enter the resident’s apartment, inform her calmly that there is an emergency. Assist the resident by giving direction on where to evacuate. Resident’s apartment is approximately 150 feet from the evacuation exit door. Resident will turn right out of her apartment and ambulate with assistance from the care aide on assignment A to the evacuation point. Once there, the care aide on assignment C will be responsible for taking the resident from the evacuation exit 300 feet to the refuge area in the front of the community. The resident may show resistance to evacuating. The loud noises and environment may make it difficult to convince resident to leave her apartment. Care aide on assignment A to offer comfort and assure the resident she will be okay and that in an emergency, the most important thing is to evacuate to a safer place. Ensure the resident you will walk by her side and get her to safety.
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Pyscho/Social Capabilities SOCIALIZATION/SPIRITUAL • Ensure that the details of the resident’s daily socialization are listed in the instructions section for the care team. Does the resident enjoy regular happy hours or certain clubs, groups or service projects? • List the programs the resident enjoys attending. List if the resident needs reminders to attend these events. • Use this section to list Signature Programs like Essence, Bookmarks, Sparks that the resident might have interest in being a part of. Remember to include all parts of the Be Inspired dimensions of wellness. • For the spiritual aspect, list parts of the resident’s life history. Did they attend church? Is this something we need to consistently provide for them to keep their rhythm? What did the resident do to maintain their spirituality throughout their life? Ensure we meet that need through various, personalized programming opportunities.
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SOCIALIZATION EXAMPLE Resident was the founder of the People’s Clinic in Cincinnati, OH. She was a fierce advocate for those less fortunate and worked tirelessly throughout her life to provide service and afford opportunities to those in her wake. She served on the board at Anywhere Medical School and was highly influential in research studies for low-income women. Resident was always well dressed; fashion was a big part of her life. She takes great pride in her appearance and her living spaces. She promoted self-care and offered many charitable services, such as education on wellbeing to low-income women in the community. Resident enjoyed social events such cocktail parties, banquets and other similar events. She was not religious in that she attended formal church services, but she was sure to complete daily meditation. Resident is set up to enroll in a Sparks semester and weekly Bookmarks book club and, as an avid gardener, has a strong desire to attend gardening club daily. Care aide to promote programming that is in line with resident’s interests. Be sure to involve her in happy hour and events with a social component.
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TRAUMATIC EVENTS • Describe for the care aide any events surrounding traumatic events and how the care aide might support the resident. • Are there certain intervention methods or techniques the care team will need to execute to offer support to the resident? Describe in detail the support plan if necessary in the instructions for this section.
TELEPHONE USE • State what type of assistance is needed for the resident. • Is there a scheduled call for the resident to speak with family? What type of support will the care aide need to provide? • Is there a designated area for the phone call? List any details the care team needs in order to provide support to the resident for this task.
TRANSPORTATION • Describe any assistance and detail surrounding this topic for the care aides in the instructions section.
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FINANCIAL MANAGEMENT • Describe any pertinent information in the instructions.
SHOPPING • Describe any support the resident might need with shopping assistance. • Will family provide items the resident needs? Will the transportation provide shopping outings for the resident? • Note any special details and added information for the care team.
HOUSEKEEPING • Please describe what the care aide needs to complete for the resident. At times, some residents may require additional housekeeping needs, especially for those who are incontinent. Be sure to list those in detail. • List, for the care team member, reminders to empty trash on each shift, make bed and lock products to maintain a Safe Haven in the Memory Care Neighborhood.
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LAUNDRY • List for the care team any special requests concerning laundry. • Be concise in directions on how to proceed with laundry. • If the family has labeled or designated drawers, be respectful of returning things to their place to facilitate the resident’s remaining abilities in locating her items.
LAUNDRY EXAMPLE Care aide on third shift will pull laundry, wash, dry and fold. Place clean laundry in the resident’s room for first shift to put away. This resident’s laundry is scheduled for Wednesday Nights, or as needed. First and Second shift will complete the laundry immediately on that shift if the resident has soiled linens or clothing due to any incontinence. Care aide to report any inconsistencies in laundry being completed to the MCD upon discovery.
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PET CARE • Does the resident have a pet? If so, what details does the care team need to support the resident? • Does the care team need to assist the resident with walking a dog? • Will the care aide need to support the resident in feeding the animal? Add details to the instructions for the care team to provide appropriate and consistent support.
SMOKING • If this resident is a smoker, what is the plan to support the resident? Is there a designated place the care aide will need to escort the resident? • Is there a schedule for when the resident can smoke? If so, list the schedule; who is responsible for supporting the resident during this activity? • Remind the care team that is a resident preference and to be accommodating to the resident when the resident expresses desire to smoke. • Communicate where the cigarettes and lighter are kept (preferably in the locked med cart).
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ALCOHOL CONSUMPTION • Describe for the care aide if this resident may consume alcohol as a preference. Include whether or not there is an alcohol order in the chart. • List any preferences such as “Resident prefers a glass of red wine with dinner.” In addition, list this in the dietary or eating sections of the care plan and reference an alcohol order from a physician in the chart. • Remind the care aide in the instructions to honor the preferences of the resident and to inform the MCD of any changes or concerns in decline with the resident.
AFFECT • Describe any fluctuating emotions, history of anxiety, current anxieties, agitation, altered perception or impaired judgment for the care aides. • Add the interventions and support plan if the resident experiences any of the above mentioned. • This section should always have added interventions and a support plan if the resident displays any of the above mentioned. • Use the Bradford Well-Being Profile to help determine the resident’s overall well-being; their positive and negative indicators of well-being
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• and the support plan in place to combat any negative indicators of well- being.
AFFECT EXAMPLE Resident may experience agitation throughout the day, especially around the evening hours. Loud music and voices contribute greatly to the resident’s agitated state. In late afternoon, just before dinner, the resident will attend a session of essence with MCD, trained care team member or programming assistant. In addition, the resident enjoys a successful mealtime experience when seated in private dining area with her friend Janet. Care aide to approach this resident with patience, kindness and a soft tone. Give the resident a head start with mealtime and ordering to prevent agitation. Report any increase in agitation or additional incidents to the MCD or HWD immediately. Ensure any incident or atypical behavior is documented on the 24-hour report so all team members are aware from shift to shift.
BEHAVIOR • Describe any behaviors the resident may be experiencing. Add the interventions and support plan for any behaviors that need to be addressed. • This section should always have added interventions and a support plan 22 if the resident displays any atypical behaviors.
• In general, describe new or ongoing behaviors here, along with each intervention the team has tried. MCD can initial and date the new intervention, indicate whether the intervention worked or not. Continue to add new interventions for each incident or event related to the resident’s behavior. • Use the Survey of Discomfort in Dementia and behavior logs to find the root cause of the behavior. Indicate the use of the tools in this section. • Remind the care team to use the 24-hour report and behavior logs to indicate whether an intervention is working or not. • The intervention is listed here with instructions for the care aide so that they may support the resident when displaying a particular behavior.
BEHAVIOR EXAMPLE [Resident] experiences sun downing in the afternoons; usually around 3 -6 pm. [Resident] can grow very agitated and will often have argumentative interactions with other residents. To support the [resident] during this time, the care partner on this assignment will offer 1:1 time by accompanying [resident] on a walk through the courtyard. [Resident] also enjoys a glass of lemonade and watching the birds. [Resident] loves to help refill the bird feeders every few days.
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On 10/27 [Resident] had an incident with another resident in the hallway outside of her apartment. She was fighting over a purse and struck another resident in the head with it. The incident took place about 2:45 pm. The resident has been showing an increase in agitation. Infection has been ruled out. Intervention: The programming coordinator will bring the resident in for a session of Essence daily at 2:30 pm. This is a 1:1 aromatherapy program. The session will last anywhere from 15 to 30 minutes depending on the residents preference. The [resident] will have a wellness plan using oils that support reduced anxiety and promote peace. Soft relaxing music will play as lavender is diffused into the quiet room. Hand massage may be used in the session if the resident is agreeable. The programming coordinator will end the session by accompanying the [resident] to the dining room for a warm cup of tea. The care partner will then resume normal rhythms and routines in the afternoon in the courtyard. The care team will report any agitation to the MCD or nurse on duty. Behavior logs will be kept for the next 7 days. Update: 11/10 [Resident] has had no further behaviors; the programming coordinator will continue this intervention for the next 6 weeks upon which the support plan will be re-evaluated.
MOOD • Describe details surrounding the resident’s mood. Is the resident withdrawn or expressing hopelessness? Are there disturbed sleep patterns? 24
• Is the resident isolating or insistent on staying in bed? • Add the interventions and support plan if the resident experiences any of the above mentioned. • This section should always have added interventions and a support plan if the resident displays any of the above mentioned. • Use the Bradford Well-Being Profile to help determine the resident’s overall well-being; their positive and negative indicators of well-being and the support plan in place to combat any negative indicators of well-being. • Describe the intervention plan to the care team members in detail. Does this include a plan for 1:1 engagement? Increased or decreased family visits?
MOOD EXAMPLE [Resident] may withdraw at times spending time in her apartment. Mornings can be tough on days where she is feeling down or low. Care partner will need to be patient and approach softly with added kindness when [resident] expresses a desire to stay in bed. If the [resident] desires to stay in bed, this does often time’s causes patient and approach softly with added kindness when [resident] expresses a desire to stay in bed. If the [resident] desires to stay in bed, this does often time’s causes restlessness and wandering in the nighttime hours.
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During the day: Staff to knock on the [resident’s] door and ask to come in. Care partner to approach [resident] by asking her how she is feeling today? Ask if she would like her favorite album to play on low; ask if you can give a hand massage while she rests in bed with her favorite lavender lotion from bath and body. Family indicates that sitting and talking with the resident in an understanding manner will help pull [resident] out of her low place. She likes to feel supported and loved by family and others around her. Care partner to assure [resident] that she is missed when she spends time in her room, and invite her to join you for a walk in the garden after the hand massage and dressing. During the evening: Care partner to engage resident in 1:1 in the late evening hours if up and restless. [Resident] enjoys a hot cup of tea while reviewing her family photo album (located in her bookshelf in her apartment.) Resident also loves to crochet, and will utilize the family room with her favorite television show on; Leave it to Beaver. Care partner to offer choices, and assist [resident] in set up. If [resident] declines, care staff to reminisce with [resident] over a hot cup of tea. [Resident] connects with staff a great deal, and enjoys when they join her in drinking tea. [Resident] has a My Page button on the IN2L that may be utilized in the evening and late night hours by the care team. Report any changes in mood to MCD or HWD immediately and via the 24-hour report.
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Cognitive Capabilities TIME/PLACE ORIENTATION • Describe in detail the resident’s orientation. What type of supervision does the care aide need to provide? • Describe whether the resident can maintain a façade of being oriented and any precautions the team might need to take to keep the resident safe. • Are there concerns with the resident’s judgment? Are there behavioral management pieces involved with care due to severe decline in orientation to person, place and time?
WANDERING • Describe in detail for the care partner behaviors or habits associated with wandering. Is the resident entering others’ apartments? • Does the resident wander at night? Indiscriminately? Frequently? Are they actively seeking for an exit or pacing?
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WANDERING EXAMPLE Resident often paces consistently up and down the hallways, occasionally stopping to enter others’ apartments. It can be challenging to get the resident to attend programming throughout the day as she has a lot of energy and enjoys moving around. She has some inclination to enter others’ apartments, pick up shiny items and carry them with her. Music seems to be the most calming for the resident. The care aide is to retrieve the Bluetooth headphones from the activity cabinet and play her favorite playlist, created by family, when she starts to wander into other people’s apartments. This keeps the resident more focused, and she even has a tendency to sit down on a bench in the hallway or along the walking path in the courtyard when her headphones are on and enjoy the music. This has shown to reduce her curiosity to enter other people’s apartments. Some of her favorite programs are walking club and morning exercise. She also enjoys getting outside for programs and gardening club. She has a difficult time sitting through programs that are not as interactive or are slower paced, such as devotionals or board games. Care aide to create opportunities to engage the resident during the day, frequently inviting and escorting her to programming. If the resident insists on pacing or walking the corridor, care aide to bring her the headphones and ask if she would like to listen to her favorite song. This resident will need increased checks by the care aide
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throughout the day, offering redirection through conversation and invitations to connect. Care aide to check on resident every 30 minutes.
MENTAL HEALTH • Describe any mental health issues and surrounding events here. • Are there any current support plans or clinical interventions in place?
DEPRESSION • Describe how this is manifesting in the resident to the care aide. • Add the support plan in detail and each intervention in place. • Does the resident need increased 1:1 engagement? Would they benefit from Essence? Do they need additional invitations to participate in programs? • Are there individualized programs that we can add to the calendar to draw the resident into new opportunities and social groups? • Add any clinical interventions needed to manage the depression here as well. • Be clear in your description on what part the care aide will play is supporting the resident with depression and what interventions they will use when the resident displays signs of depression.
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ALCOHOL/SUBSTANCE ABUSE • Describe any details surrounding the resident’s history concerning alcohol or substance abuse and any support plan the care team might need to provide appropriate support to the resident.
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