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Making Care Plans Work
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:
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:
At the meeting:
Care Plan Checklist
A good care plan should:
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 Rights, Care Standards, Transfer and Discharge Rights, Family Councils, How to File a Complaint, and other topics.
Page Last Modified: October 24, 2019