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Assessment and Care Planning
in Nursing Homes
 
What are assessment and care planning?

Georgia and federal law require nursing homes to identify each resident's abilities and needs and to develop a plan to maximize residents abilities and meet their needs. The process of identifying a resident's abilities and needs is called an assessment. The plan describing how the nursing home will meet the resident's needs is called a care plan.

Why are assessment and care planning important?

Every nursing home resident has individual abilities and needs requiring special attention. A nursing home cannot meet a resident's needs unless it identifies those needs. Once a resident's abilities and needs are identified, a home must create a written care plan to address each need. Due to the large number of staff members, frequent turnover, and use of temporary staff members in many nursing homes, clearly written care plans are essential to assure that the staff understands what care each resident needs and how, when and why it is to be given.

What kind of assessment is required?

All Georgia nursing homes must begin an assessment of new residents within 24 hours. Federal law, which applies to Medicare and Medicaid certified nursing homes, is specific about how assessments must be conducted. Most nursing homes are certified by Medicare or Medicaid.

Using a standard assessment form, Medicare and Medicaid certified nursing homes must collect information on a resident's background, customary routines, and needs and abilities in the following areas:

  • hearing, speech, vision and dental care
  • skin condition
  • help needed with bathing, dressing, toileting and eating
  • control of bowel and bladder
  • nutritional issues, such as ability to swallow and need for special diets
  • medication use
  • mood and behavior
  • health conditions
  • comprehension and thought process
  • mental health status
  • special treatment procedures
  • rehabilitation potential
  • activities and interests

The initial assessment must be completed within 14 days of admission. Assessments must be updated at least every three months. Residents must also be assessed whenever there is a significant change in their condition. Otherwise, residents must be fully assessed at least once a year.

The nursing home should interview the resident and resident's family or legal representative during the assessment. A copy of the assessment should be kept in the resident's medical record. Residents and their authorized representatives have a right to review the assessment and other medical records.

What are the care planning requirements?

  • Care plans in all Georgia nursing homes must include objectives and timetables describing how a resident's medical, nursing, and social needs will be met.
  • Medicare and Medicaid certified nursing homes must develop the care plan within 7 days after the assessment is completed.
  • Care must be provided in a way that prevents any decline in a resident's abilities or condition unless the decline cannot be prevented due to illness.

Residents and their family members have a right to participate in the care planning process.

What is a resident care plan meeting?

Care plan meetings are periodic meetings of health care professionals such as nurses, doctors, therapists, dieticians and social workers to discuss and evaluate a resident's needs. When changes in a resident's needs are identified, the care plan must be revised to address those needs.

A care plan meeting should be held as needed, but at least every 90 days for each resident. Many nursing homes routinely invite residents and their representatives to attend care conferences. These meetings, if conducted properly, offer a good opportunity to discuss current concerns. Residents and their representatives should seek an invitation to the care plan meetings if their home does not routinely ask them to attend.

Residents can use the conference to get questions answered, to raise objections about current practices and to provide information to the staff. The care plan meeting should be conducted at a time and in a manner which fosters resident participation.

I Would Like To Live In the Community

The options for returning to the community rather than living in the nursing home are improving. Attending a care plan meeting is a good way to let the nursing home social worker know that you would like to explore the options and to get more information for you and your family. Also, your local ombudsman can refer you to the local Aging and Disabilities Resource Center at any time.

Summary

Assessment and care planning are critical to good nursing home care. Done properly, these evaluations help improve the quality of care and quality of life in nursing homes. Involvement of the resident, family members and other representatives is essential to provide the information and feedback needed to establish a sound and workable plan.

With the resident's permission, the Community Ombudsman can attend the care plan conference. 

IMPORTANT NOTICE

The information contained in this web site applies only to GEORGIA, USA. It is intended only as INFORMATION and does not constitute legal ADVICE, nor does reading, downloading or otherwise using this site create an attorney-client relationship.  Anyone seeking specific legal advice should contact an attorney licensed in the appropriate state, and should never rely upon the information provided herein, or any other web site, for that matter.