Page 73 - Ombudsman Participant Manual Optimized_Neat

Care Plan Tip Sheet
Resident

n

a
i
a
n

How Can Ombudsman Help Resident Participate the Care Plan Process?
Introduction
n
f
i
Living skilled nursing facility presents many challenges for some residents. There are many different types staff
o
a

providing care and services in a facility. Coordinating those services in a way that reflects the resident’s personal goals

a

i
i
s

and preferences often difficult for both residents and advocates. The Care Plan process wonderful tool for
s

addressing issues and achieving resolution of concerns. The process brings all modalities together – with the resident –

a

and constructive dialogue can be had regarding issues. s always, our first goal as ombudsmen should be to assist the

A

I

i

resident n self-advocacy and self-resolution. f that is not an option, a Tier-II trained ombudsman can use the Care Plan

process tool to achieve results on behalf of the resident.

s

a

a

This resource is intended to help ombudsmen empower a resident to understand and participate in the care plan process.

i
s

What “Care Plan”?
a

• A document that defines the needs of a nursing home resident and lists the interventions that the facility will

employ o meet those needs.
t

• A fluid document that is intended to be updated as needed and “driven” by a detailed assessment process.

• A person-centered “plan of care” – meaning how the facility plans on helping the resident meet needs and

achieve goals.
b

t
f
• A Care Plan is required Department Health/CMS for each resident admitted the nursing home.
o
y

o

• An initial, baseline care plan must be developed within 48 hours of admission

• A Care Plan must be in place within 21 days of admission and every quarter thereafter – unless there is a

i

significant change. s important to remember that the quarterly reviews are the minimum required threshold;

t
I

Care Plans can be reviewed and revised more frequently.

t
o
o
t
• The 2016 revisions the federal nursing home regulations now require facilities expand the inter-disciplinary

care team and to create a person-centered care plan for each resident

s

i

What the Long-Term Care Ombudsman’s Role in the Care Plan Process?

We remain resident advocates. One of our primary roles is to educate residents about the purpose of the Care Plan and

their right to participate in that process. Often, residents are unaware that this document exists and that this document

drives their care. y empowering a resident to participate in the Care Plan process, the resident now has a consistent

B

vehicle for impacting routine and approach – resulting in a resident-directed plan of care. Because the process can be a

little complex and perceived overwhelming, residents may ask ombudsman to the Care Plan meeting with

s
a
attend
n
a

them. That is perfectly fine. However, if an ombudsman is asked to participate in the discussion or to
t
s
i
b
negotiate/suggest/trouble-shoot, etc. the ombudsman performing casework. The ombudsman must careful o
e

l
a
document their work appropriately, obtain consent, resident-direction and fulfill the requirements for the essential

f

l
o
f
a
elements case.
o
Office of the LTC
Office of the LTC OmbudsmanOmbudsman
Version 1.0 September 20202020
Version 1.0 September
73
73