Working with a Nursing Home or Long-Term Care Facility
Federal regulations require nursing homes and other long-term care facilities to establish a Baseline Care Plan within 48 hours of a new resident's arrival. A Comprehensive Care Plan must be created within 21 days of arrival. Comprehensive Care Plans must be reviewed and revised after every comprehensive assessment and quarterly review assessment. While the content of these plans is similar, the Comprehensive Care Plan is created after a full evaluation of the resident. Facilities are required to involve the resident and/or their representative in the creation and revision of these plans. It is important that you understand and convey the wishes and needs of the IP and involve them in the creation of the plan to the extent possible.
The Comprehensive Care Plan must:
Be individualized
Align with the resident's goals and desired outcomes
Meet all needs identified in the comprehensive assessment including:
Contain measurable goals that include timeframes and service staff efforts necessary to reach those goals
Allow for the highest degree of autonomy and independence possible
Contain a discharge plan and referrals, as appropriate
Document any refusals of care on the part of the resident or their representative and the discussion of consequences of and alternatives to the refused care
Include culturally competent trauma-informed care and services
Medical
Nursing
Mental Health
Psychosocial
You may need to advocate for the IP's needs and desires in residential care settings, so it is important to ask who within the facility is your point of contact, as well as who you should contact if the first person is unavailable, or you have further concerns.
While it is important to visit the IP in person frequently in order to observe their care and condition, between these visits you may consider calling the staff for an update or contacting the IP directly to see how they are doing. Your presence and consistent communication will allow you to be the best possible advocate and support for the IP. Be sure to document all conversations and visits including the date, time, and purpose of the visit or call, as well as who you spoke with and what you spoke about.