RCFE / Assisted Living Fact
Sheets:
Assessment & Care Planning
Assessment, sometimes called appraisal in Residential
Care Facilities for the Elderly, is a process to gather information about
a person's life, functional abilities and needs in order to develop
an individualized plan of care. The plan of care describes the
strategies that the facility and staff will use to enhance, restore or
maintain a person's optimal physical, mental and psychosocial well-being.
What Kind of Information Does the Facility Want to Know About a Resident?
The Residential Care Facility (RCFE) is required to complete a pre-admission
appraisal that evaluates a prospective resident's functional capabilities,
mental condition and such social factors as likes, dislikes and interests.
A Medical assessment, completed within the past year, must also
be completed including a diagnosis, examination for TB and other contagious
diseases, medical history, record of medications, identification of physical
and mental limitations which might prevent person from receiving adequate
care at RCFE level. Note: For residents with dementia, there must
also be a written plan by the resident's doctor to minimize the use of
psychoactive medications.
Why Does the Facility Need to Know All This Information?
The detailed and comprehensive information provided in the assessment
gives the facility a "whole picture" of the resident.
The information helps tell a person's story, giving insight into
their strengths, interests, likes and dislikes, routines, habits and patterns
of daily living. For example, this type of information can transform a
resident with a diagnosis of dementia in room 12 into a real person. Facilities
can then create an individualized plan that will provide quality of care
and enhance quality of life.
When Will the Facility Want to Obtain This Information?
The RCFE is required to obtain most of this information before admitting
someone as a resident. Either prior to admission or within 2 weeks
after being admitted, the facility must meet with the resident and his/her
family, agent or legal representative to develop a care plan.
What is the Role of the Resident and Family Members or Representatives
in the Assessment & Care Planning Process?
The resident, family and legal representatives have the right to participate
in the assessment, reassessment and care planning process. Their role
is essential to providing a complete picture of the resident. Note:
The resident also has a right to refuse treatment and services, once advised
of their benefits and risks, and the offer of alternative treatment approaches.
What Happens at a Care Plan Meeting?
The Care Plan meeting provides an opportunity
to see if the plan is meeting the needs of the resident by reviewing what
strategies are working and which ones are not. It can identify
changes in the resident's condition or behavior that will require
revisions of the care plan. The meeting also gives residents, family members
or representatives, as well as facility staff, a chance to discuss and
resolve problems and concerns.
How Will I Know if the Care Plan is Working?
The true measure of a good care plan is the degree to which it meets
the person's care needs and enhances the quality of life. Other
important criteria for evaluating a care plan are:
- Is the plan resident-centered and individualized?
- Is it understandable to the resident, family and to the staff?
- Does it clearly indicate what is to be done, by whom, how and by when?
- Is staff consistently following the plan?
If the care plan is not working, request
a meeting to review the care plan. Also ask that other persons with expertise
be consulted, (e.g., doctor, nurse, social workers, Ombudsman, etc.), and
be involved in the care planning process.
How Often Will the Care Plan Be Reviewed?
RCFEs are supposed to make a reassessment and care plan revisions
at least annually. However, a reassessment and care plan update are
required whenever there are significant changes in the resident's
physical, medical, mental, and/or social condition. Ask for a quarterly
review. This allows for mutual feedback, adjustments in the care plan
and preventive intervention.
The
most pertinent laws and regulations are found in California Health &
Safety Code Section 1569.80 and in California Code of Regulations, Title
22, Sections87569, 87578, 87579, 87583 through 87588.
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