Standards › Standard 28 › Policies
Policy · LTC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 28.1
At a glance
- Every resident receiving rehabilitation or restorative therapy has an individual plan built from a documented functional assessment (LTC-FRM-003).
- The plan aims to maintain function and slow decline, not to assume an acute recovery.
- Function is tracked with a validated tool at set intervals (LTC-REG-002).
- A resident who loses function triggers a review of the plan.
- Stop and get help straight away if: a resident stops walking after a hospital stay and no plan is made to restore it.
1. Purpose
To make sure residents receive a functional plan that fits long-term care (28.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A resident in long-term care who loses function slowly can be left to decline unless someone plans to keep them moving. An individual maintenance plan, built from the assessment, is what keeps the resident as active as possible.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for long-term care | Owns the functional plan rule | Clinician or manager |
| Rehabilitation or therapy lead | Writes and reviews each plan | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Assess.
- Carry out a documented functional assessment on admission and at set intervals.
Key point: Assessed.
Step 2. Plan.
- Write an individual plan for maintenance and restoration, on LTC-FRM-003.
Key point: Planned.
Step 3. Review.
- Review the plan on decline or at the set interval.
Key point: Reviewed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Residents with a functional plan from assessment | 100% | Monthly | Clinical lead for long-term care | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| LTC-FRM-003 | Functional maintenance plan record | Record |
| LTC-REG-002 | Functional status measurement register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on digital and AI governance. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)