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Care Plan Meetings

Updated: Mar 5, 2021

Care plans are required in all federally funded long-term care facilities. Any facility that accepts Medicare or Medicaid is required to have a care plan meeting. This means that Assisted Living and Residential Care facilities are not required to have care plan meetings since they do not provide Medicare or Medicaid (cash grant does not apply). A care plan is a meeting where all the department heads involved in a resident’s care get together and discuss the care plan for each resident every three months.

When a resident is first admitted to a facility, the facility staff has 14 days to complete the resident's complete evaluation. Within 7 days from the evaluation, the facility must have the initial care plan meeting. Families are to be invited to the care plan meetings. During these meetings, the staff will discuss the resident's medical status with problems outlined and goals set for addressing the problems for the next three months. Family members will be allowed to discuss their concerns and have staff work out a plan of action to address their concerns.

How to Prepare for Your Care Plan Meeting

1. Make a point to have your loved one at the care plan if they can participate. The staff should address your loved ones and listen to what they want.

2. Come prepared – make a list of any questions/concerns you would like to have addressed. Without a list, it is easy to forget some of the areas you needed to discuss.

3. Take an active part in the discussion. Remember, you know your family member better than anyone. Offer the staff resolutions that have worked for your loved one in the past. Let them know what’s been tried and did not work. If you have ideas of something that may work, let the staff know.

4. Once the plan is in place, there should be a “plan of action” covering the expected outcomes from the meeting. If you have voiced concerns, make sure what the facility has offered to do to fix any concerns are detailed in the care plan notes. Then make sure to follow up with the appropriate department head to give feedback on what changes you have noticed (both positive and negative!)

5. You have a right to have an advocate present with you at the care plan meeting as long as your loved ones agree. You could consider contacting the Long-Term Care Ombudsman Program. These are federally mandated advocates for residents in long-term care facilities.

When facilities schedule care plans, they usually only allow 15 minutes per resident. If you have concerns, you would like to discuss and need more time than that, call the Care Plan Coordinator and tell them that you will require more time and schedule accordingly. After a care plan meeting, the Care Plan Coordinator will pass on any concerns you had with the appropriate department heads for follow-through. Please give them a couple of weeks to correct any problems. If you find that the problems are not being addressed, call the community, and talk to the department head involved; if the problem is a nursing issue talk to the Director of Nursing; if it is a dietary issue, talk to the Head of Dietary, etc.

Remember, you are your loved one’s best advocate, don’t be afraid to take an active role!

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