Cognitive & Behavioral Care
Cognitive & Behavioral Care
MANDATORY
5 criteria
| Standard 5.1 NON-NEGOTIABLE · Standard 5: Cognitive & Behavioral Care Behavioral Expressions Are Understood as Communication, Not Managed as Problems |
ASSESSMENT ASF-LTC-STD5-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 5.1 NON-NEGOTIABLE L1 |
THE STANDARD Behavioral Expressions Are Understood as Communication, Not Managed as Problems Staff are trained to understand behavioral expressions — agitation, resistance to care, repetitive movement — as genuine communication of an unmet need or distress, with a specific process to identify and address the underlying cause, not a default response aimed only at stopping the behavior itself. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Are staff trained to understand behavioral expressions as communication of an unmet need, not as problems to be stopped? Genuine understanding of behavior as communication, not framed only as disruption to manage. Doc: Staff training record on behavioral expressions |
YES | PARTIAL | NO |
| 2 | Is there a specific process to identify the underlying cause behind a behavioral expression? A real, structured process, not an assumption that the cause is simply the dementia itself. Doc: Behavioral assessment documentation |
YES | PARTIAL | NO |
| 3 | Does the response address the identified underlying need, not only aim to stop the visible behavior? A response matched to the genuine cause, not suppression of the behavior alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Staff training review |
Reviews training content for genuine coverage of behavioral expressions as communication. |
| DOCUMENT Underlying cause assessment review |
Reviews documentation for a structured process identifying the cause behind behavioral expressions. |
| OBSERVE Response practice observation |
Observes an actual staff response to a behavioral expression for genuine cause-directed care. |
REFERENCES
- [21] Cohen-Mansfield J. The Unmet Needs Framework for understanding behavioral expressions in dementia, as applied in current long-term care practice, identifies behavior as communication of underlying emotional or physical distress rather than pathology to be suppressed, requiring identification and response to the genuine underlying need.
| Standard 5.1 · Standard 5: Cognitive & Behavioral Care Guidance & Learning |
GUIDANCE ASF-LTC-STD5-v3.0 |
| WHY THIS STANDARD EXISTS |
A behavior that looks disruptive from the outside is often the only way a resident with advanced dementia can communicate hunger, pain, overstimulation, or fear, and responding only to suppress the behavior — rather than understanding and addressing what's actually driving it — leaves the genuine underlying need unmet, and often makes the behavior worse.
| WHAT GOOD LOOKS LIKE ✓ Staff genuinely understand and describe behavioral expressions as communication. ✓ A structured process identifies the underlying cause behind each expression. ✓ Responses address the genuine underlying need, not just the visible behavior. |
WHAT FAILURE LOOKS LIKE ✗ Staff describe behaviors only as problems to manage or stop. ✗ No structured process exists to identify underlying causes. ✗ Responses aim only to suppress the visible behavior, regardless of its cause. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Understanding is strong among nursing staff but less consistently reinforced with support staff who spend significant time with residents.
Any staff member interacting with a resident benefits from genuinely understanding behavior as communication.
2 Cause identification happens for more disruptive expressions but not consistently for quieter, less visible ones.
A quieter expression of distress deserves the same genuine attention as a more visible one.
3 The underlying cause is identified but the response doesn't consistently address it directly.
Identifying a cause without a genuinely matched response doesn't provide the real benefit this approach is meant to offer.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current staff understanding and training on behavioral expressions as communication.
Week 2 Establish a structured underlying-cause assessment process.
Week 3 Train all staff, including support roles, on cause-directed response.
Ongoing Review behavioral response practice using real, recent examples.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a staff member to describe a recent behavioral expression and what they believe was actually driving it.
A specific, thoughtful answer reveals genuine understanding, not a memorized framework.
Ask a support staff member, not only nursing staff, about their understanding of behavioral expressions.
This reveals whether the approach genuinely extends beyond clinical staff.
| E-LEARNING academy.gmj.ge/ltc-std5-1-behavioral-expressions — 30 min · complete before self-assessment |
| Standard 5.2 NON-NEGOTIABLE · Standard 5: Cognitive & Behavioral Care Wandering Risk Is Assessed Using a Validated Tool, Not Informal Judgment |
ASSESSMENT ASF-LTC-STD5-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 5.2 NON-NEGOTIABLE L1 |
THE STANDARD Wandering Risk Is Assessed Using a Validated Tool, Not Informal Judgment Every resident with cognitive impairment is assessed for wandering and elopement risk using a validated, structured tool, at admission and after any significant change — not an informal, subjective judgement about which residents seem likely to wander. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is every resident with cognitive impairment assessed for wandering risk using a validated, structured tool? A specific, validated assessment, not an informal staff impression. Doc: Wandering risk assessment record |
YES | PARTIAL | NO |
| 2 | Is the assessment repeated after any significant change in the resident's cognitive or physical condition? Genuine reassessment reflecting the resident's current, actual risk, not a one-time evaluation. Doc: Reassessment record |
YES | PARTIAL | NO |
| 3 | Does the assessment result specifically inform the resident's individual care plan? Genuine, individual application of the assessment, not a result recorded without practical use. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Assessment tool review |
Reviews the specific, validated tool used for wandering risk assessment. |
| DOCUMENT Reassessment record review |
Reviews evidence that assessment is repeated after significant condition changes. |
| DOCUMENT Care plan application review |
Reviews whether assessment results specifically inform the individual care plan. |
REFERENCES
- [22] Algase DL, Beattie ERA, Antonakos C, Beel-Bates CA, Yao L. Wandering and the physical environment. Am J Alzheimers Dis Other Demen. 2010 — establishes structured, validated wandering risk assessment, including the Algase Wandering Scale, as the standard for identifying elopement and wandering risk in long-term care, distinct from informal staff judgement.
| Standard 5.2 · Standard 5: Cognitive & Behavioral Care Guidance & Learning |
GUIDANCE ASF-LTC-STD5-v3.0 |
| WHY THIS STANDARD EXISTS |
Wandering is genuinely common — a majority of residents with dementia will experience at least one episode — and informal judgement about who is at risk is measurably less reliable than a structured, validated assessment that's specifically designed to capture the actual risk factors involved.
| WHAT GOOD LOOKS LIKE ✓ Every resident with cognitive impairment receives a validated, structured wandering risk assessment. ✓ Reassessment genuinely happens after significant condition changes. ✓ Assessment results specifically inform the individual care plan. |
WHAT FAILURE LOOKS LIKE ✗ Wandering risk is judged informally, without a structured, validated tool. ✗ Assessment happens only once, never updated as the resident's condition changes. ✗ Assessment results are recorded but don't inform the actual care plan. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Assessment happens at admission but reassessment after a cognitive decline isn't consistently triggered.
Wandering risk can change significantly as cognitive impairment progresses.
2 The tool is used but not consistently by all staff conducting assessments.
Consistent, correct use across all assessing staff is what makes a validated tool genuinely reliable.
3 Assessment results are documented but the care plan doesn't specifically reflect identified risk factors.
An assessment that doesn't translate into individual care planning provides limited real protective value.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current wandering risk assessment practice for validated tool use versus informal judgement.
Week 2 Train staff on consistent, correct administration of the validated assessment tool.
Week 3 Establish a specific reassessment trigger tied to significant condition changes.
Ongoing Confirm assessment results are genuinely reflected in individual care plans.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see the actual validated assessment tool used, not a general description of risk judgement.
A specific, named tool is the real evidence of structured, validated practice.
Ask how a specific resident's wandering risk assessment translated into their actual care plan.
A specific, real example reveals genuine application, not assessment for its own sake.
| E-LEARNING academy.gmj.ge/ltc-std5-2-wandering-assessment — 30 min · complete before self-assessment |
| Standard 5.3 NON-NEGOTIABLE · Standard 5: Cognitive & Behavioral Care Elopement Prevention Balances Genuine Safety With Resident Autonomy |
ASSESSMENT ASF-LTC-STD5-v3.0 |
| CR ADAPTED | TR FULL | SM ADAPTED | ST FULL |
| 5.3 NON-NEGOTIABLE L1 |
THE STANDARD Elopement Prevention Balances Genuine Safety With Resident Autonomy Elopement prevention measures are individualized and proportionate to actual assessed risk, genuinely balancing safety with the resident's autonomy and freedom of movement — not a blanket, facility-wide restriction, such as a locked unit, applied to every resident regardless of individual risk or need. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Are elopement prevention measures individualized to the resident's actual assessed risk, not applied as a blanket facility-wide restriction? Genuine individualization matched to real risk, not uniform restriction regardless of individual need. Doc: Individualized elopement prevention plan |
YES | PARTIAL | NO |
| 2 | Do residents with lower assessed risk retain genuine freedom of movement, not restricted by default? Real, preserved autonomy for lower-risk residents, not restriction applied to everyone regardless of risk level. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is there a specific, documented justification when a more restrictive measure is genuinely used for a specific resident? Specific, individual justification, not a default facility-wide policy. Doc: Restrictive measure justification documentation |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Individualization review |
Reviews elopement prevention plans for genuine individual tailoring to assessed risk. |
| OBSERVE Autonomy preservation observation |
Observes whether lower-risk residents genuinely retain freedom of movement. |
| DOCUMENT Restrictive measure justification review |
Reviews specific, individual documented justification for any more restrictive measure used. |
REFERENCES
- [23] Individualized, proportionate elopement prevention measures, balanced against resident autonomy and freedom of movement, are established practice in long-term care dementia management, distinct from blanket facility-wide restriction applied without individual justification.
| Standard 5.3 · Standard 5: Cognitive & Behavioral Care Guidance & Learning |
GUIDANCE ASF-LTC-STD5-v3.0 |
| WHY THIS STANDARD EXISTS |
A locked unit or restrictive environment might reduce elopement risk, but it also removes a resident's freedom of movement entirely, and established long-term care principles specifically require services that attain or maintain a resident's highest practicable well-being — a standard that a blanket restriction, applied without genuine individual justification, works directly against.
| WHAT GOOD LOOKS LIKE ✓ Elopement prevention is genuinely individualized to actual assessed risk. ✓ Lower-risk residents retain genuine freedom of movement. ✓ Any restrictive measure carries specific, individual documented justification. |
WHAT FAILURE LOOKS LIKE ✗ A blanket, facility-wide restriction is applied regardless of individual risk. ✗ All residents face the same restriction regardless of their actual assessed risk level. ✗ Restrictive measures lack specific, individual justification. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Individualization is genuine for the physical environment but less so for daily activity scheduling.
Autonomy and safety balance extends beyond physical space alone to how a resident's day is genuinely structured.
2 Lower-risk residents have some freedom but staff practice is inconsistent in genuinely respecting it.
A policy of preserved autonomy needs consistent staff practice to provide real protection of resident freedom.
3 Restrictive measures are individually justified initially but not periodically reconsidered as risk changes.
A resident's genuine risk level can change, and restriction should be reconsidered accordingly, not left static.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current elopement prevention practice for genuine individualization versus blanket restriction.
Week 2 Establish individualized prevention plans matched to actual assessed risk.
Week 3 Train staff on genuinely preserving autonomy for lower-risk residents.
Ongoing Periodically reconsider restrictive measures as individual risk genuinely changes.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see elopement prevention plans for two different residents with different risk levels.
Genuinely different plans reveal real individualization; identical plans reveal a blanket approach.
Ask a lower-risk resident or their family about their actual freedom of movement in daily practice.
This tests lived experience, not just policy intent.
| E-LEARNING academy.gmj.ge/ltc-std5-3-elopement-autonomy-balance — 30 min · complete before self-assessment |
| Standard 5.4 NON-NEGOTIABLE · Standard 5: Cognitive & Behavioral Care Dementia Care Staff Receive Specific, Ongoing Training, Not General Orientation Alone |
ASSESSMENT ASF-LTC-STD5-v3.0 |
| CR ADAPTED | TR FULL | SM ADAPTED | ST FULL |
| 5.4 NON-NEGOTIABLE L1 |
THE STANDARD Dementia Care Staff Receive Specific, Ongoing Training, Not General Orientation Alone Staff providing direct care to residents with dementia receive specific, ongoing dementia care training — communication techniques, behavioral expression response, person-centered approach — not a single general orientation session treated as sufficient for the duration of their employment. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Do staff providing direct dementia care receive specific training beyond general orientation? Specific, dementia-focused training content, not folded into general orientation alone. Doc: Dementia-specific training record |
YES | PARTIAL | NO |
| 2 | Is this training genuinely ongoing, not a single session treated as sufficient indefinitely? Real, recurring training, not a one-time requirement. Doc: Ongoing training schedule |
YES | PARTIAL | NO |
| 3 | Can staff demonstrate specific dementia care skills — communication technique, behavioral response — not just describe general awareness? Genuine, demonstrable skill, not familiarity with the concept alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Training content review |
Reviews training content for specific dementia care focus, not general orientation alone. |
| DOCUMENT Ongoing training schedule review |
Reviews the schedule and actual delivery of recurring dementia care training. |
| OBSERVE Skill demonstration observation |
Observes staff demonstrating specific dementia care communication and response skills. |
REFERENCES
- [24] Tilly J, Reed P. Dementia Care Practice Recommendations for Assisted Living and Nursing Homes. Chicago: Alzheimer's Association — establishes specific, ongoing dementia care training, including communication techniques and person-centered approach, as distinct from general staff orientation, as a core practice recommendation for long-term care.
| Standard 5.4 · Standard 5: Cognitive & Behavioral Care Guidance & Learning |
GUIDANCE ASF-LTC-STD5-v3.0 |
| WHY THIS STANDARD EXISTS |
Dementia care requires genuinely specific skills that differ meaningfully from general caregiving, and a single orientation session, however thorough, doesn't provide the ongoing reinforcement and skill development that genuinely effective dementia care requires over the course of a career.
| WHAT GOOD LOOKS LIKE ✓ Staff receive specific, dementia-focused training distinct from general orientation. ✓ Training is genuinely ongoing and recurring, not a single session. ✓ Staff can demonstrate specific, genuine dementia care skills. |
WHAT FAILURE LOOKS LIKE ✗ Dementia care content is folded into general orientation with no specific focus. ✗ Training happens once and is never repeated or reinforced. ✗ Staff can describe general awareness but cannot demonstrate specific skills. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Initial training is specific and thorough but ongoing reinforcement is inconsistent.
Skill retention and development genuinely benefit from recurring reinforcement, not a strong single session alone.
2 Nursing staff receive specific training but support and ancillary staff receive less.
Any staff member interacting with residents benefits from genuine dementia care skill, not clinical staff alone.
3 Training covers communication technique well but behavioral expression response less thoroughly.
Both are genuinely distinct, important skills, and training should cover both with real depth.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current dementia care training for specificity versus general orientation content.
Week 2 Build or strengthen specific training content covering communication and behavioral response.
Week 3 Establish a recurring training schedule reaching all staff who interact with residents.
Ongoing Assess staff skill demonstration periodically, not just training completion.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a support staff member, not only nursing staff, about their dementia care training.
This reveals whether specific training genuinely reaches everyone who interacts with residents.
Ask staff to demonstrate, not just describe, a specific communication technique.
Demonstration reveals genuine skill, not just familiarity with training content.
| E-LEARNING academy.gmj.ge/ltc-std5-4-dementia-staff-training — 30 min · complete before self-assessment |
| Standard 5.5 CORE · Standard 5: Cognitive & Behavioral Care A Resident's Individual Life History Genuinely Shapes Their Care |
ASSESSMENT ASF-LTC-STD5-v3.0 |
| CR N/A | TR FULL | SM ADAPTED | ST FULL |
| 5.5 CORE L1 |
THE STANDARD A Resident's Individual Life History Genuinely Shapes Their Care Each resident's individual life history — career, family, meaningful roles, personal preferences — is genuinely gathered and actively used to shape their daily care and activity engagement, not collected once as an intake formality and never referenced again. |
| FACILITY SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is each resident's individual life history genuinely gathered, not skipped or treated as optional? Real, gathered life history information, not an assumption it's unnecessary or too difficult to obtain. Doc: Life history documentation |
YES | PARTIAL | NO |
| 2 | Is this information actively used to shape daily care and activity engagement, not filed away unused? Genuine, ongoing use, not information collected once and never referenced. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Can staff describe a specific way a resident's life history has genuinely shaped their care approach? A specific, real example, not a general statement that life history is considered. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Life history gathering review |
Reviews documentation for genuine, gathered individual life history for each resident. |
| OBSERVE Care application observation |
Observes whether life history information is genuinely reflected in actual daily care and activities. |
| ASK Staff example interview |
Asks staff for a specific example of a resident's life history shaping their care approach. |
REFERENCES
- [25] Edvardsson D, Winblad B, Sandman PO. Person-centered care of people with severe Alzheimer's disease: current status and ways forward. Lancet Neurol. 2008;7(4):362-367 — establishes genuine use of individual life history and personhood, not cognitive status alone, as foundational to effective person-centered dementia care.
| Standard 5.5 · Standard 5: Cognitive & Behavioral Care Guidance & Learning |
GUIDANCE ASF-LTC-STD5-v3.0 |
| WHY THIS STANDARD EXISTS |
Person-centered dementia care is grounded in the understanding that personhood and identity aren't lost with cognitive decline, and a resident's genuine life history is often the key to understanding what a specific behavioral expression means, or what activity would genuinely engage them — information gathered but never used provides none of this real value.
| WHAT GOOD LOOKS LIKE ✓ Individual life history is genuinely gathered for every resident. ✓ Life history information is actively used to shape daily care and activities. ✓ Staff can describe specific, real examples of life history shaping care. |
WHAT FAILURE LOOKS LIKE ✗ Life history gathering is skipped or minimal. ✗ Information is collected but never referenced in actual daily care. ✗ Staff cannot describe any specific example of life history informing care. |
| MOST COMMON REASONS FACILITIES SCORE PARTIAL |
1 Life history is gathered at admission but not updated as family provides additional information over time.
A resident's history often emerges gradually through ongoing family relationships, not only at a single intake conversation.
2 Information is used for activity planning but less consistently for understanding behavioral expressions.
Life history carries real value for interpreting behavior, not only for planning activities.
3 Some staff genuinely use this information but it isn't consistently shared across the full care team.
Genuine benefit depends on this information reaching everyone providing care, not staying with whoever gathered it.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current life history gathering practice for completeness and genuine depth.
Week 2 Establish a process for life history information to genuinely reach the full care team.
Week 3 Train staff on connecting life history to both activity planning and behavioral understanding.
Ongoing Update life history documentation as new information emerges through family relationships.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a staff member for a specific detail from a resident's life history and how it shapes their approach.
A specific, real answer reveals genuine use, not documentation for its own sake.
Ask a family member whether they feel the facility genuinely knows their relative as an individual.
This tests lived experience of person-centered care, not documentation completeness alone.
| E-LEARNING academy.gmj.ge/ltc-std5-5-life-history-care — 30 min · complete before self-assessment |
Long-Term Care Standards — overviewFacility Classification — Which Type of Facility Are You?Standard 1 — Admission & Resident RightsStandard 2 — Living Environment & SafetyStandard 3 — Personal Care & Daily LivingStandard 4 — Clinical & Medical CareStandard 5 — Cognitive & Behavioral CareStandard 6 — End-of-Life & Palliative CareStandard 7 — Governance & StaffingStandard 8 — Medical TourismStandard 9 — Health & MigrationReferences & Index
STANDARD 5Cognitive & Behavioral Care5.1 Behavioral Expressions Are Understood as Communication, Not Managed as Problems5.2 Wandering Risk Is Assessed Using a Validated Tool, Not Informal Judgment5.3 Elopement Prevention Balances Genuine Safety With Resident Autonomy5.4 Dementia Care Staff Receive Specific, Ongoing Training, Not General Orientation Alone5.5 A Resident's Individual Life History Genuinely Shapes Their Care
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