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Care Plan Meetings 101

Updated: Oct 6, 2022

To understand how care is provided, it is important to understand three primary concepts. The first is that the nursing home is your elderly loved one’s “home” and he or she has the right to be treated with dignity, like a resident, rather than a patient. The second is that your loved one is in charge of his or her own care. The third is the nursing process itself. Basically, the nursing process is a repeating cycle: assess, plan, implement the plan (or treat the patient), and re-assess. Anytime something changes, the nursing staff is supposed to factor that change into the plan.

What the Law Says

Federal law provides that the resident has the right to (1) choose a personal attending physician; (2) be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident’s well-being; and (3) unless a court has determined that the resident is incompetent, to participate in planning care and treatment of changes in care and treatment.

What Do You Need to Know about Assessment and Care Planning?

Every nursing home resident has a right to receive good care. The law says each resident must receive, and the nursing home must provide, the necessary care and services to help residents “attain or maintain” their highest level of well-being – physically, mentally and emotionally. Care must be provided in accordance with a comprehensive assessment and plan of care.

Initially and periodically, the facility must conduct a comprehensive, accurate of each resident’s functional ability. The facility is expected to observe and communicate with the resident: these are the primary sources of information when completing the assessment. The staff must assess each resident’s individual needs and develop a plan the care to support the resident’s life-long patterns, and current interests, strengths and needs. Resident and family involvement in care planning give the staff information they need to make sure residents get good care. Keep in mind, one reason why the law requires the nursing home to look at factors other than the resident’s medical care is because the resident “lives” there – it is home.

What Is a “Resident Assessment”?

Assessments gather information about how well residents can take care of themselves, and when they need help with “functional abilities” such as walking, talking, eating, dressing, bathing, remembering, and so on. Staff also ask about the resident’s habits, activities and relationships so they can help residents live more comfortably and feel more at home.

Federal law requires the facility to examine the following: demographic information; customary routine; cognitive patterns; communications; vision; mood and behavior patterns; psycho-social well-being; physical functioning and structural problems; continence; disease diagnoses and health conditions; dental and nutritional status; skin condition; activity pursuit; medications; special treatments and procedures; discharge potential; and other factors where additional assessments are triggered.

The assessment helps staff look for what is causing a problem. For instance, poor balance could be caused by many different things ranging from medications, sitting too much, weak muscles, poor fitting shoes, a urinary tract infection or an ear ache. Until the staff knows what caused the problem, they won’t know how to treat it. This is another reason why the residents needs to speak up when he or she isn’t feeling well or when they notice a problem.

What Is a “Plan of Care”?

A plan of care is a “game plan” or “strategy” for how the staff will help a resident. It must be in writing. It tells each staff member what to do and when to do it (e.g., dietary aide will place water on the right side because Mrs. Jones has left side paralysis). One reason the care plan is so important is because many tasks are performed by aides who do not have the extensive training that is required of doctors and nurses. Without proper instructions in a care plan, the aides might not know what needs to be done.

Federal law provides that a plan of care must include measurable objectives and timetables to meet a resident’s needs. What this means is that broad generalizations are insufficient. The care plan should include specific actions that will be taken for the resident. The plan must describe the services that are to be furnished to “attain or maintain” the resident’s highest level of physical, mental and psycho-social well-being and any other services that would be provided if the resident had not refused them.

Care plans must be reviewed regularly to make sure they work. They must be revised as needed. The best care plans make the resident feel like his or her needs are being met and are consistent with the resident’s goals and values. Care plans can address any medical or non-medical problem (e.g., a roommate who is not compatible).

What Is a “Care Plan Meeting”?

At a care plan meeting, staff and residents/families talk about life in the facility – meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents/families can bring up problems, ask questions, or offer information to help staff provide care. A representative from each staff group working with the resident should be involved – nursing assistants, nurse, physician, social worker, activities staff, dietician, occupational and physical therapists.

Federal law provides that, to the extent possible, the resident, the resident’s family, or the resident’s legal representative should participate in the care plan meeting. When the resident participates, the staff should listen and use language that the resident can understand. If the resident doesn’t understand something, he or she should ask for additional explanation. Whether you’re a resident or a family member, if you ask for something and they tell you no, don’t be afraid to ask why. Seek specific answers to your questions. Obviously, you will catch more flies with honey than with vinegar, but in a nice way you should insist that any concerns you have are addressed. If you agree on some course of treatment, or on the resolution to a problem, ask the staff to make sure it will go into the plan of care.

How Often Are Care Plan Meetings Held?

Care plan meetings must occur every three months, and whenever there is a big change in a resident’s physical or mental health that might require a change in care. The care plan must be done within 7 days after an assessment. Assessments must be done within 14 days of admission and at least once a year, with reviews every three months and when there is a significant change in a resident’s condition.

What Should You Talk About at the Care Plan Meeting?

Whether you’re a resident or a family caregiver, it’s vital to talk about what is important to you during the care plan meeting. If you need something, then talk about what you need. If you think something is working, then say so. If something isn’t working, then let the staff know and ask them to try something else. Ask questions about care and the daily routine, about food, activities, interests, staff, personal care, medications, how well you get around. If you don’t make your concerns known, you can’t expect the staff to read your mind.

Staff must talk to you about treatment decisions, such as medications and restraints, and can only do what you agree to. You may have to be persistent about your concerns and choices.

How Can Residents and Their Families Participate in Care Planning?

Residents have the right to make choices about care, services, daily schedule and life in the facility, and to be involved in the care planning meeting. Participation is the only way to be heard.

Before the Meeting

  1. Tell staff what you want, what’s working, what’s not working, how you feel, your concerns, and what questions you have; plan your agenda of questions, problems and goals for yourself and your care.

  2. Know, or ask your doctor or staff, about your condition, care and treatment.

  3. Ask staff to hold the meeting when your family can attend if you want them there.

During the Meeting

  1. Discuss options for treatment and for meeting your needs and preferences. Ask questions if you need terms or procedures explained to you.

  2. Be sure to understand and agree with the care plan and feel it meets your needs. Ask for a copy of your care plan; ask with who to talk if you need changes made (e.g., if you hate carrots and they keep serving you carrots at every meal, you should speak up and let them know you’d like something else).

After the Meeting

  1. See how your care plan is being followed. Talk with nurse’s aides, other staff or the doctor about it.


  1. Support your relative’s agenda, choices and participation in the meeting.

  2. Even if your relative has dementia, involve him/her in the care planning as much as possible. Always assume he/she may understand and communicate at some level. Help staff find ways to communicate with and work with your relative.

  3. Help watch how the care plan is working and talk with staff if questions arise.

What’s In a Good Plan of Care?

A good plan should:

  1. Be specific, individualized and written in common language that everyone can understand (if you speak English, then it should be in PLAIN ENGLISH).

  2. Reflect resident’s choices and support resident’s well-being, functioning and rights; not label resident’s choices or needs as “problem behavior”

  3. Be re-evaluated and revised routinely – watch out for plans that never change.

Questions about an elderly loved one’s care? Takacs McGinnis Elder Care Law may be able to help. Just give us a call at 615.824.2571.


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