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Hoffman DiMuzio lawyers explain the benefit of a care plan

As the "Baby Boom" population ages, more and more people are entering into assisted living facilities and nursing homes. As attorneys, we understand the importance of documentation, especially when that documentation applies to the health and well-being of our elders.

What is a Nursing Home Care Plan?

A care plan is a document specific to each nursing home resident that identifies all of their medical issues, the treatments the staff is supposed to provide to treat those issues, and a list of goals to reflect the expected improvement their medical condition. A federal law known as “OBRA” requires nursing homes to provide a multi-disciplinary team of caregivers charged with ensuring that the nursing home resident receives the care and services needed to ensure that the resident reaches and maintains “the highest practicable degree of physical, mental, and psychosocial well-being.” This team is primarily made up of physicians, nurses, physical therapists, social workers, and dieticians (and essentially any other discipline involved in the resident’s care).  To deliver on the quality of care the resident and their family were promised by the nursing home, the team must develop a comprehensive care plan that provides a framework for the staff whom are responsible for treating the resident on a day-to-day basis.  To be effective and comprehensive, the care planning process must include the input of all caregivers involved in the care of the resident.

Care planning is an essential part of properly caring for a nursing home resident. A good care plan provides a "road map" of sorts, to guide all involved with a resident's care.  A caregiver that was just hired, or is coming back to work from a vacation can look at the care plan developed for a resident and know exactly what needs to be done to care for that resident.  A care plan is not a stagnant or stationary document.  The care plan changes just as the resident’s condition changes.  The care plan needs to be reviewed and updated by the caregivers, especially when there is a change in the resident’s condition.

What is a Care Plan Conference?

Care plans should be created at a care plan conference held at the nursing home.  The resident, and their family members, should be involved in the conference.  The nursing home should invite the resident, and their family members to attend the conference.  If they don’t, the resident, and their family members should tell the nursing home Administrator that they want to be present at the conference.  At the care plan conference, the resident’s medical issues are identified and the treatments that the staff is supposed to execute to care for the resident are set forth.  Goals for improvement are set.  Whether the resident’s health improves, or declines, the care plan needs to be adjusted to reflect the best way to treat the resident at that time.

It is important for the family to attend the care plan conferences because they can discuss what they know about the resident to ensure that the resident’s medical issues are properly identified.  It is also important for the family to discuss and understand treatment strategies and goals with the caregivers.  Understanding a resident’s care plan will help the family understand what should be happening at the nursing home, and to bring it to the attention of the Administrator and resident’s physician if the family feels the care plan is not being followed.  Not following the care plan can often lead to debilitating falls and pressure ulcers for the resident.

Relevant Federal Statute concerning Care Plans

§483.20(d) (A facility must…) use the results of the assessment to develop, review and revise the resident’s comprehensive plan of care.

§483.20(k) Comprehensive Care Plans

  • (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs  identified in the comprehensive assessment. The care plan must describe the following:
  • (i) The services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25; and
  • (ii) Any services that would otherwise be required under §483.25 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

Speak with an attorney who cares

If you wish to discuss other ways to lower the chance your loved one is injured at a nursing home, or to discuss your family's legal rights relative to your experiences with a nursing home, feel free to call Ernest L. Alvino, Jr., (856-381-4837) at Hoffman DiMuzio. Ernie limits his practice to representing families who experience nursing home abuse and neglect, and he will explain to you what the nursing home was required to do.

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