Updated: Oct 6
What is a Plan of Care?
A plan of care, or care plan, is a “game plan” or “strategy” for how the nursing home staff will help a resident. The plan of care 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.
Care plans must be reviewed regularly to make sure they work. They must be revised as needed. The best care plans work to make the resident feel like his or her needs are being met and are consistent with the resident’s goals and values.
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, dietitian, 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 you participate, the staff should listen to you and should use language you understand. If you don’t understand something, ask that they explain it to you. If you ask for something and they tell you no, don’t be afraid to ask why. Seek specific answers to your questions.
Care Plan Meeting Frequency
Care plan meetings must occur every three months, and whenever there is a major 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.
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
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.
Know, or ask your doctor or staff, about your condition, care and treatment.
Ask staff to hold the meeting when your family can attend if you want them there.
During the Meeting
Discuss options for treatment and for meeting your needs and preferences. Ask questions if you need terms or procedures explained to you.
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
See how your care plan is being followed. Talk with nurse’s aides, other staff or the doctor about it.
Support your relative’s agenda, choices and participation in the meeting.
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.
Help watch how the care plan is working and talk with staff if questions arise.
The Takacs McGinnis Elder Care Law staff is always happy to answer client questions on the topics of care planning. Just give us a call at (615) 824-2571.