Care Plans

Care planning is a requirement for all nursing homes. A care plan says how the staff at a nursing home will help your loved one. Care plans are developed with a nursing home resident in mind, and help to address all aspects of nursing home living, including both medical and non-medical concerns. These reports are revised during care planning conferences, where you can talk with nursing home staff about your loved one’s care. This is a time when you can speak up about any concerns you may have for your loved one.  There is a process (including steps) for how and when a care plan is developed which you can find below.

The care plan should, above all else, be centered on the resident.  This is the primary way to make sure a resident gets the care and attention he or she deserves. As a representative for your loved one, do not be afraid to strongly advocate for your loved one’s needs, desires, and goals in developing a care plan.

The steps in creating a care plan are as follows:

1. A baseline care plan must be completed by the nursing home within 48 hours of the resident’s admission. The facility must give a summary of the plan to the resident and his/her representative.  Prior to November 28, 2017, only doctor’s orders were used upon admission, until the first care plan was completed within 21 days of admittance. So the 48-hour care plan is good progress on more quickly and better understanding resident needs.

2. The initial comprehensive resident assessment – identifying the physical and mental status of the resident and areas noted for the best possible care — must be completed within 14 days of admission. A resident assessment determines how well the resident can take care of him/herself and areas where the resident may need extra assistance (i.e., getting dressed). The resident’s habits and preferred activities are also noted. Such detailed information is used by the nursing home to help a resident feel more at home, identify any problems (e.g., poor balance), what could be causing those problems, and the best way to address them.

3. A comprehensive care plan is then developed within seven days of the initial comprehensive resident assessment, and can be readdressed at any time.  You can bring up changes to the care plan with the nursing home staff at any time.

4. Comprehensive assessments and care plans should be conducted – whenever a significant change in the resident’s physical and/or mental health condition occurs — or at least every 12 months, if there are no significant changes in the resident’s physical or mental health status.

5. Care planning conferences to discuss or revise care plans happen every three months or whenever there is a significant change in the resident’s physical or mental health that could require a change in care. This is a meeting where you and the resident can talk about his/her feelings about life in the nursing home, and ask questions about anything and everything from medical treatment decisions to food in the nursing home. This is a time where you should be a strong advocate for your loved one.

NOTE: A resident assessment includes observing and speaking with the resident and speaking with direct care staff from all shifts.  Assessments must take into consideration the resident’s needs, strengthens, goals, life history and personal preferences.

An interdisciplinary team develops the care plan based on the resident assessment. The team includes, but is not limited, the doctor, registered nurse and CNA (certified nursing assistant) responsible for the resident, and member of the dietary team.  The care plan should document objectives and time frames for meeting the resident’s needs, indicate care goals and services to be provided, and also report services the resident has refused.

Some tips for care planning and care plan meetings include:

• The quarterly care plan meetings are typically 15-minutes. You need to be prepared, knowing what you want to discuss and what you want to accomplish in the meeting.

• If necessary, you can phone into a meeting and/or ask to reschedule if you cannot attend the suggested time.

• It’s especially important to write down your thoughts, ideas, suggestions, needs, etc., to avoid forgetting them in the meeting.

• Talk to your loved one about what he/she would like to see as part of his/her care, and their personal concerns about care or life at the nursing home in general.

• During the care planning meeting, ask any and all questions that you or your loved one want to ask.

• Talk with others who have visited your loved one (e.g. family, friends) and get their perceptions of the care your loved one is receiving, the atmosphere in the nursing home, etc.

• If you or your loved one has any preferences for medical care (including medications), write those down so you can bring them up during the care planning meeting.

• Feel free to seek advice from the local LTC Ombudsman as to what questions should be asked and what issues should be raised in a care planning meeting.

• Follow up with staff at the nursing home to make sure the care plan is being followed. This can be done at the care planning meeting or at any time.

And remember, there is no need to wait until the next care planning meeting to raise issues.  A good and responsive nursing home should always be available and willing to discuss these issues.

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