The nursing home staff will get your health information and review your health condition to prepare your care plan. You (if you're able), your family (with your permission), or someone acting on your behalf has the right to take part in planning your care with the nursing home staff.
The basic care plan includes:
A health assessment (a review of your health condition) that begins on the day you’re admitted, and must be completed within 14 days of admission
A health assessment at least every 90 days after your first review, and possibly more often if your medical status changes
Ongoing, regular assessments of your condition to see if your health status has changed, with adjustments to your care plan as needed
Nursing homes are required to submit this information to the federal government. This information is used for quality measures, nursing home payment, and state inspections.
Depending on your needs, your care plan may include:
What kind of personal or health care services you need
What type of staff should give you these services
How often you need the services
What kind of equipment or supplies you need (like a wheelchair or feeding tube)
What kind of diet you need (if you need a special one) and your food preferences
How your care plan will help you reach your goals
Information on whether you plan on returning to the community and, if so, a plan to help you meet that goal
Things You Should Know About Care Plan Meetings After transitioning an aging spouse or relative into a Skilled Nursing Care center, many wonder how they can stay involved and ensure their loved one’s care needs are being met.
Visiting regularly and getting to know staff members are two ways to keep an eye on the type of care a relative is receiving. The best way to be informed, however, is being involved in care plan meetings.
At the beginning of each resident’s stay, care centers are required under federal regulations to assess the individual’s abilities and care needs. Those assessments are then incorporated into a care plan that outlines the types of services the resident will require and acts as a roadmap for facility staff.
Scheduled on a quarterly basis and attended by residents, families and facility staff, care plan meetings are used to review and adjust individual care plans. They are an opportunity to share your loved one’s personal preferences and ensure their medical and non-medical needs are being met to your satisfaction.
Here are three ways to get the most out of your loved one’s care plan meeting:
Share background information – Sharing your loved one’s personal preferences and likes/dislikes with staff members can improve the quality of care your loved one receives. For instance, informing staff of sleeping patterns, dietary restrictions and other pertinent information can deeply impact your loved one’s daily life.
Raise questions and concerns – Before the meeting, make a list of any questions and concerns you want to raise at the meeting. Perhaps you notice a change in your relative’s health or wonder if your loved one needs new clothes or personal items. Or maybe you noticed your loved one isn’t eating as much. Regardless of what you bring up to staff members at the meeting, it is always important to do so in a mutually respective manner.
Take notes – During the meeting be sure to jot down any information you would like to discuss with your loved one, other family members or staff members. Before the meeting ends, review your notes and make sure all of your questions have been answered.
Care plan meetings are essential to ensuring quality care. If your loved one is not offered a comprehensive assessment on a quarterly basis and a subsequent care plan, notify your state’s ombudsman.
A recent study found that 37 percent of skilled nursing homes fail to meet care planning and discharge requirements, and fail to provide services consistent with and required by the residents' care plans. The federal government paid billions and billions of dollars for nursing home stays in which the certified nursing facilities failed to provide required services in accordance with the care plans. Much of the care failures involved supervision of residents, wound care, and medication management. These finding raise real concerns over the federal government's lax oversight and what exactly Medicare is paying these nursing homes for.
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