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Making Care Plans Work


During a nursing home stay, you and your family have the right to be involved in developing a meaningful and effective care plan. The nursing home must work with you to develop an individualized, written care plan and must update it at least quarterly and any time your condition changes.

As a resident, one of your most important rights is to receive good care. To give good care, the nursing home staff must plan to support your needs, abilities, interests and preferences. Under the law, residents and families are partners in this 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. If you get involved in the care planning process, it is almost certain that you will get better care and enjoy a higher quality of life.

Assessment—The First Step

Assessment is a way of learning important information about a resident so that an individualized care plan can be developed. The staff members need to get a "whole picture" of who you are. Otherwise, it is likely that your needs will go unmet and your preferences unnoticed. Knowledge about who you are helps build respect and understanding—two critical ingredients of dignified care.

The nursing home is required to do a comprehensive assessment. 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 and at least once a year after that. Reviews are held every three months and any time that your condition changes.

Plan of Care

Within seven days after the assessment is completed, the nursing home must create an initial care plan that addresses all of your needs and concerns. If done properly, the care plan is a custom made strategy for how the staff will help you every day.

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 could be more important to you than treatment plans. A good care plan should:

  • Be specific to you by reflecting your concerns and desires;
  • Support your well–being and rights;
  • Use a team approach involving a variety of staff and outside referrals as needed;
  • Include specific goals;
  • Assign tasks to specific staff members;
  • Be written in common language everyone can understand; and
  • Be updated as your needs change.

Resident and Family Participation in Care Conferences

Care planning conferences are held soon after admission and at least every three months to design and update the care plan. You and your family have the right to be invited and involved in each meeting. It is a great opportunity to make sure your care plan honors your choices about care, services, daily schedule, and life in the nursing home.

A good care conference takes time, sometimes an hour or more. Ask the staff to plan sufficient time and to hold the meeting when you and people you want to attend are available. If you have favorite staff persons, such as trusted nursing assistants, ask that they be invited. 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.

During the meeting, the staff should explain care options and ask you about your needs and preferences. 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. You don’t have to accept staff care recommendations unless you agree with them and feel they meet your needs. 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.

Choosing and Refusing Care

You have the right to choose or refuse any care or treatment offered to you, at any time and for any reason. The nursing home and your doctor must tell you in advance about care and treatment they are planning and seek your informed consent. This means they must give you pertinent information about treatment options and the possible benefits and consequences. You or your legal representative have the final say in all decisions.

You cannot 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.

Rights of Family Members

Many nursing home residents rely on family members to speak up for them. You may be surprised that family members have specific legal rights to participate in nursing home matters. As a family member, you have the right to:

  • Participate in assessments and care planning;
  • Be informed of residents’ rights;
  • Immediate access to visit the resident at any time, subject, of course, to the resident’s consent;
  • Be notified within 24–hours of an accident resulting in injury, a significant change in the resident’s condition, a need to alter treatment significantly, or a decision to transfer the resident;
  • Be notified promptly if the resident is going to be moved to another room or if there is a change of roommates; and
  • Participate in a family council and make recommendations and present grievances without retaliation.

You do not need special legal authority to exercise these rights. Typically, the right to be notified about certain matters is exercised by the resident’s next of kin, legal representative or someone else designated by the resident or the family at admission. Nursing homes must record and periodically update the address and phone number of the designated family member so that timely information can be shared.

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 Residents’ Rights, Restraint Free Care, Care Standards, Family Councils, Planning for Long Term Care and related matters at www.canhr.org.

Note: This fact sheet summarizes pertinent laws and regulations found at: 42 USC §§1396r(b)(2)&(3) and (c); 42 CFR §§483.10, 483.20 & 483.15(c); California Code of Regulations, Title 22, Division 5, §§72311, 72527, & 72528; and California Health and Safety Code §§1418.4 & 1599.1(i).

If you would like a copy of CANHR’s booklet on organizing family councils, would like assistance in organizing a family council, or more information on resident’s rights please contact CANHR at (800) 474–1116.

Page Last Modified: February 25, 2013