Making Care Plans Work

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One of your most important rights as a nursing home resident is to receive the necessary care and services to “attain or maintain the highest practicable physical, mental and psychosocial well-being” in accordance with a written plan of care.  42 USC §1396r(b)(2), 42 CFR §483.21. In other words, you have the right to the very best care possible.

A care plan is a written guide on how to accomplish this key right. The nursing home must engage you and your representatives in a thorough and thoughtful care planning process that produces a comprehensive, individualized plan designed specifically for you.

Under the law, residents and their representatives are partners in the care planning process. You have the right to give information, ask questions, participate in care plan meetings, offer suggestions, review care plan documents and accept or refuse offered care. 42 USC §1396r(b)(2)(B), 42 CFR §483.21(b)(2).

Assessment—The First Step

Assessment is a way of learning important information about you so that an individualized care plan can be developed. The staff members need to get a “whole picture” of who you are. Knowledge about who you are helps build respect and understanding—two critical ingredients of dignified care.

The nursing home is required to conduct a comprehensive assessment of your needs, strengths, goals, life history and preferences, using a uniform assessment established by the federal Centers for Medicare & Medicaid Services (CMS). 42 USC §1396r(b)(3), 42 CFR §483.20.

It must gather information about your health and physical condition and identify what type of help you need. The assessment must also examine your routines, habits, activities and relationships in order to help you live more comfortably and feel at home in the facility.

You can help by sharing important information about yourself. Describe what makes a good day for you. Discuss your goals, such as plans for discharge or hopes of improved health and independence.

Assessments must be done within 7 days of admission. 22 CCR §72311. Reviews are held every three months. Comprehensive assessments must be conducted every 12 months and any time there is a significant change in your condition. 42 CFR §483.20(b)&(c).

Baseline Care Plan

Nursing homes that participate in Medicare or Medi-Cal must complete and implement a baseline care plan for each resident within 48 hours of admission. 42 CFR §483.21(a).

The purpose of the baseline care plan is to give initial instructions on necessary care until a comprehensive care plan is established. At a minimum, it must address initial goals based on admission orders, physician and dietary orders, and therapy and social services.

The facility must give you and your representative a summary of the baseline care plan.

Comprehensive Care Plans

The baseline care plan is soon replaced by a comprehensive care plan.

Within seven days after the assessment is completed, the facility must establish a comprehensive person-centered care plan. 42 USC §1396r(b)(2), 42 CFR §483.21, 22 CCR §72311. Person-centered means that you, as the resident, have as much control as possible during care planning and in day-to-day decisions. The nursing home must support you in making your own choices.

The care plan must describe the services you will receive to attain or maintain the highest practicable physical, mental and psychosocial well-being.

The plan shall also document and address your preferences and potential for future discharge and identify any referrals to local agencies for this purpose. Nursing homes are required to develop and implement an effective discharge planning process. 42 CFR §483.21(c).

Who Develops the Care Plan?

Care plans are developed by an interdisciplinary team (IDT) that includes, at a minimum, your attending physician, a registered nurse and nurse aide with responsibility for you, a member of the dietary staff, and other appropriate staff or professionals in disciplines as determined by your needs or as you have requested. 42 CFR §483.21(b)(2).

Most importantly, you and your representatives must participate to the extent practicable.

The facility must help you engage in the care planning process. 42 CFR §483.10(c)(3)(i). This means helping you and your representatives understand the assessment and care planning process, holding care planning meetings when you are functioning best, planning enough time for discussion and decision making, and encouraging your representatives to participate in care planning conferences. Guidance on 42 CFR §483.21 at F657, Appendix PP to CMS State Operations Manual.

Additionally, the facility must give you and your representatives sufficient advance notice of care conferences to enable your participation. This participation can take many forms, such as holding care conferences at a time your representative is available to participate, holding conference calls or video conferencing. Guidance on 42 CFR §483.21 at F657, Appendix PP to CMS State Operations Manual.

Care planning conferences are held soon after admission, whenever there is a significant change in your condition and at least every three months to design and update the care plan. 42 CFR §483.21(b).

Your Rights in the Care Planning Process

You have important rights in the care planning process. They include the right to:

  • Participate in the development and implementation of your person-centered plan of care. 42 USC §1396r(b)(2) & (c)(1)(A)(i), 42 CFR §483.10(c)(2), 42 CFR §483.21, 22 CCR §72527(a)(3).
  • Identify individuals or roles to be included in the care planning process. 42 CFR §483.10(c)(2)(i).
  • Request meetings and request revisions to your plan of care. 42 CFR §483.10(c)(2)(i).
  • Participate in establishing the expected goals and outcomes of care; the type, amount, frequency and duration of care; and any other factors related to the effectiveness of your plan of care. 42 CFR §483.10(c)(2)(ii).
  • Have your personal and cultural preferences incorporated into your care plan. 42 CFR §483.10(c)(3)(iii).
  • Advance notice of changes to the plan of care. 42 CFR §483.10(c)(2)(iii).
  • Receive the services and/or items included in your care plan. 42 CFR §483.10(c)(2)(iv).
  • See your care plan, including the right to sign after significant changes to it. 42 CFR §483.10(c)(2)(v).

Your Right to Refuse Care

You also have the right to choose or refuse any care or treatment offered to you, at any time and for any reason. 42 CFR §483.10(c)(6), 22 CCR §72527(a)(4) & 72528.

The nursing home and your doctor must tell you in advance about care and treatment they are planning and seek your informed consent. 42 USC §1396r(c)(1)(A)(i), 42 CFR §483.10(c)(5), HSC §1418.9, 22 CCR §72527(a)(3)&(5), 22 CCR §72528. This means they must give you pertinent information about treatment options and the possible benefits and consequences. You or your representative have the final say in all decisions.

You should not be neglected or evicted if you refuse care or treatment. A nursing home is obligated to identify and present alternative care approaches that address your goals and concerns. Guidance on 42 CFR §483.10(c)(6) at F578, 42 CFR §483.15(e)(1) at F626, and 42 CFR § 483.21(b) at F656, Appendix PP to CMS State Operations Manual.

Advocacy Tips on Care Planning Conferences

You and your representatives have the right to be invited to and involved in each and every care plan meeting. It is an important opportunity to make sure the nursing home honors your choices about care, services, daily schedule, and life in the facility.

However, some nursing homes just go through the motions during care planning conferences. If that is the case at your facility, you will need to assert your rights to prevent that from occurring.

Consider the following tips.

Before the meeting:

=>Ask the staff to plan sufficient time and to hold the meeting when you and the people you want to attend are available. A meaningful care conference takes time, sometimes an hour or more.
=>Ask the staff to address any communication or language barriers. This is their duty.
=>If you have favorite staff persons, such as trusted nursing assistants, ask that they be invited. You have the right to do so.
=>Plan your list of questions, needs, problems and goals. If there is a current care plan, ask to see a copy. Think about the need for any changes.

At the meeting:

=>Don’t be afraid to speak up. If you need help, ask someone you trust to speak for you.
=>Ask questions about anything you don’t understand.
=>Use the meeting to discuss what is most important to you. Good care plans address all aspects of life in the nursing home, not just your immediate health needs. For example, a problem getting along with your roommate might be as important to you as your treatment plans.
=>You don’t have to accept staff care recommendations unless you agree with them and feel they meet your needs. During the meeting, the staff should explain care options and ask you about your needs and preferences.
=>Find out who you should talk to if changes are needed in the care plan or if there are problems with the care being provided.
=>Last but not least, ask for a copy of the written care plan. Make sure it reflects the agreements made at your meeting.

Care Plan Checklist

A good care plan should:

Be specific to you by reflecting your concerns, needs and desires (person-centered)
Support your well-being and your rights
Address both your quality of life and quality of care at the facility
Comprehensively address your needs, interests and preferences
Be developed by a team involving a variety of staff and others you know and trust
Include specific goals and timelines
Assign tasks to specific staff members
Be written in common language everyone can understand
Be known and followed by everyone involved with your care
Be updated as your needs or choices change

More About Good Care

California and federal laws protect your right to get good care. Learn more about your rights by reviewing CANHR Fact Sheets on Resident RightsCare StandardsTransfer and Discharge RightsFamily CouncilsHow to File a Complaint, and other topics.