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Documenting Dementia Capable Care1. Therapists should identify the person’s best ability to function, based on theirassessment and identification of the patient’s Allen Cognitive Level (ACL) and selecttreatment goals and methods that maximize those abilities.2. The short term goal is to match the assistance given to the person’s current ability tofunction. The long term goal is to observe an improvement in ability to function within agiven time period.3. Treatment goals should be stated as functional goals. Functional goals state what thepatient will do and give a reason for the behavior. Goals match the person’s best abilityto function at the present time.4. The assessment of ability to function is divided into three parts: what the person can do,will do and may do.5. Therapists should have a major role in discharge planning to make sure the remainingabilities are used safely. The discharge summary must indicate the skilled adaptationsand training provided for maintaining functional levels or prevention of risks or declinerelated to the chronic illness.Discharge planning should include:- education of the person’s caregiver about what is the person’s best abilityto function- what type of cognitive and physical assistance is required, and- what safety precautions are applicable to the person. Copyright Synergy Care, Inc. 2019. CONFIDENTIAL – Synergy Care, Inc. Proprietary Document

1Goal ExamplesLTG:PT/OT/ST(DCCLTG) (Who) will (reason for referral/problem) with (BATF-cog and physical assistance) provided (who?) to (prevent,minimize or maintain) within (timeframe)STG:PT-OT-ST(ACL1) Pt will respond to (sensory stimulation) with automatic actions of (desired action) to prevent or minimize (reasonfor referral/problem), with sensory stimulation provided by a competent caregiver.PT(ACL2PT) Pt will transfer with (verbal, visual and/or tactile) cues and minimum physical assist, as provided by acompetent caregiver.(ACLLow3PT) Pt will ambulate from resident room to dining room three times daily using a rolling walker with (verbal,visual and/or tactile) cues and minimum physical assist, as provided by competent caregiver.(ACLLow4PT) Pt will perform LE HEP with (verbal, visual and/or tactile) cues, and minimum physical assist, as provided bya competent caregiver.OT(ACL2OT) Pt will feed self with (level of cognitive assist) cognitive assist, as provided by a competent caregiver.(ACLLow3OT) Pt will perform oral hygiene with (level of cognitive assist) cognitive assist, as provided by a competentcaregiver.(ACLLow4OT) Pt will complete a morning ADL care routine with (level of cognitive assist) cognitive assist, as provided bya competent caregiver.ST(ACL1AwarenessSLP) The resident will respond to stimulation of environment sounds demonstrated through variationsin arousal or physical effect on ( out of occasions).(ACL2ST) Pt will identify target vocabulary used in ADLs in response to closed ended questions with (verbal, visual and/ortactile) cues, as provided by a competent caregiver.(ACL2.2NamingSLP) The resident will identify target vocabulary used in ADLs in response to open-ended responses orcloze techniques on ( out of occasions).(ACL2.6/8RepetitionSLP) The resident will produce familiar phrases in unison with the facilitator on ( out ofoccasions).

2Goal Examples(ACLLowSLP) Pt will state basic and/or social needs with (verbal, visual and/or tactile) cues, as provided by a competentcaregiver.(ACL3.4Language) The resident will generate simple phrases using verb ing constructions on ( out ofoccasions) while participating in ADLs or social events.(ACL3.8Expression) The resident will state basic and/or social needs when prompted with relevant content words orrevised verbal attempts on ( out of occasions).(ACLLow4SLP) Pt will generate a daily activity list with (verbal, visual and/or tactile) cues, as provided by competentcaregiver.(ACL4.2WhQuestions) The resident will respond to “wh” questions about anticipated or scheduled events usingvisual/graphic cues on ( out of occasions).(ACL4.8Memory) The resident will generate a daily activity list with minimal assistance over (number of days)consecutive days.(ACL4MemoryBook) Resident will utilize a memory book, which includes a daily activity schedule with (percentage)accuracy with intermittent verbal cues to increase orientation and decrease perseveration.(ACL4Attention) Resident to attend/concentrate on a structured tasks for 30-minute intervals with intermittent verbalcues for redirection.(ACL3ReceptiveLanguage) Resident to demonstrate functional usage of an ADL object appropriately for receptivelanguage ability with (percentage) accuracy, with extended time for processing and with environmental setup.(ACL3Naming) Resident will name three objects used during functional tasks with (percentage) accuracy with extendedtime for processing and with environmental setup.(ACL3Attention) Resident to attend/concentrate on a structured task for 15 minute intervals with intermittent verbal,visual and tactile cues for redirection and with environmental setup.(ACL2Singing)Resident will sing a refrain for a song with continuous auditory cues to strength vocal cords, increase lungcapacity and reduce risk of aspiration.(ACL2Attention) Resident to attend/concentrate on a structured tasks for five-minute intervals with constant verbal,visual and tactile cues for redirection and with environmental set-up.(ACL1SensoryStim) Resident will respond vocally to sensory stimulation three times per session with constant verbalcues to increase management of secretions/excretions.These examples are from the Dementia Capable Care: Dementia Therapy Applications book created by Kim Warchol- Dementia CareSpecialists/Crisis Prevention Institute.

1Goal Examples**Some goals may apply to more than one discipline**Grooming(Grooming3.0) Pt will grasp grooming objects. Caregiver will provide familiar safe objects and will cue with associatedaction.(Grooming3.2) Pt will initiate familiar actions of brushing, combing. Caregiver will supervise and provide assistance toavoid harmful effects, ensure effective results.(Grooming3.4) Pt will maintain grooming actions and cooperative with caregiver assistance. Caregiver will provide toolsand objects and appropriate supervision to avoid harmful or undesirable effects.(Grooming3.6) Pt will note effects and will imitate changes in location and duration of actions. Caregiver will supervise,provide appropriate assistance to avoid harmful effects.(Grooming3.8) Pt will recognize completion of grooming tasks. Caregiver will supervise and provide appropriateassistance to avoid harmful effects. Caregiver will arrange for long-term or special dental care.(Grooming4.0) Pt will complete familiar routine of grooming with assistance in set-up and to avoid harmful effects.Caregiver will provide familiar tools in accessible locations; will supervise use of new and potentially dangerous tools andmaterials. Will schedule dental check-ups.(Grooming4.2) Pt will complete familiar routine of grooming tasks with assistance to avoid harmful effects. Caregiver willassist with error correction and supervise use of harmful materials.(Grooming4.4) Pt will complete familiar routine of grooming with assistance to avoid harmful effects. Caregiver willassist with error correction and supervise use of harmful materials and new procedures and products.(Grooming4.6) Pt will complete familiar grooming routines with some variations from his or her standard performancewith assistance to avoid harmful or undesirable effects. Caregiver will assist with error correction and supervise use ofnew or potentially harmful products.(Grooming4.8) Pt will correct perceived errors one at a time in grooming tasks and will follow explanations of harmfulsecondary effects to be avoided in shaving, dental, nail and hair care. Caregiver will monitor use of new supplies andprovide explanations of potential hazards.(Grooming5.0) Pt will complete routine grooming care independently with assistance to avoid harmful effects in newtasks. Caregiver will explain secondary effect and provide assistance with spatial and surface properties.(Grooming5.2) Pt will complete routine grooming care independently with assistance to avoid harmful effects in newtasks. Caregiver will explain and provide secondary effects and provide assistance with spatial properties.(Grooming5.4) Pt will complete routine grooming care independently with assistance to avoid harmful effects in newtasks Caregiver will explain secondary effects and consequences of failing to consider social rules governing appearance.(Grooming5.6) Pt will complete routine grooming care independently with assistance to avoid harmful effects in newtasks. Caregiver will explain potential harmful secondary effects of new procedures/products.

2Goal ExamplesDressing(Dressing2.0) Pt will move arms, legs, trunk in response to cues to assist with dressing. Caregiver will dress pt, applyadaptive equipment to avoid medical complications.(Dressing2.2, .4, .6) Pt will push arms and legs through garments when cues to assist with dressing. Caregiver will dresspt, apply adaptive equipment to avoid medical complications.(Dressing2.8) Pt will use grab bars or other objects for stability while dressing. Caregiver will dress pt, apply adaptiveequipment to avoid medical complications.(Dressing3.0) Pt will grasp garments when these are handed to him/her. Caregiver will select and assist with donningclothes and adaptive equipment.(Dressing3.2) Pt will grasp and begin correct actions of donning familiar garments. Caregiver will select and assist withdonning clothes and adaptive equipment.(Dressing3.4, .6) Pt will complete dressing with caregiver assistance. Caregiver will provide appropriate assistance.Caregiver will provide appropriate assistance, check results and correct errors. Caregiver will monitor for correctadjustment of donned items.(Dressing3.8) Pt will dress self and recognize completion with assistance in selection and donning. Caregiver will provideassistance in selection and donning, will check results and correct errors. Will apply and adjust adaptive equipment.(Dressing4.0) Pt will initiate and complete dressing at customary time of day with assistance in selection and donning.Caregiver will provide assistance in selection and donning, will check results and correct errors. Will apply and adjustadaptive equipment.(Dressing4.2) Pt will select clothing based on matching cues and will don common garments independently. Caregiverwill provide assistance as necessary with new garments, fasteners, and will monitor and correct dressing errors.Caregiver will apply and monitor complex adaptive equipment.(Dressing4.4) Pt will initiate and complete dressing using familiar combinations of clothing with assistance with new anddifficult fasteners. Pt will apply simple splint or other devices with assistance. Caregiver will provide assistance asnecessary with new garments, fasteners, and will monitor and correct dressing errors. Caregiver will apply and monitorcomplex adaptive equipment.(Dressing4.6) Pt will dress self independently and will vary combinations one feature at a time. Will apply simple splintsor pre-adjusted slings. Caregiver will provide assistance as necessary with new garments, fasteners, and will monitor andcorrect dressing errors. Caregiver will apply and monitor complex adaptive equipment.(Dressing4.8) Pt will select garments considering all striking features with caregiver assistance to consider secondaryeffects. Caregiver will provide assistance as necessary with new garments, fasteners, and will monitor and correctdressing errors. Caregiver will apply and monitor complex adaptive equipment. Caregiver will monitor fit and function ofcomplex adaptive equipment to avoid medical complications.