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Michigan and federal law require nursing homes to identify the abilities and needs of each resident and develop a plan of care based on this evaluation. 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 call a "care plan".

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

All Michigan nursing homes must begin an assessment of new residents within 24 hours. Michigan rules do not give much more detail on how the assessment should be conducted, However, federal law as it applies to Medicare and Medicaid certified nursing homes is quite specific. 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 patterns
• health conditions
• comprehension and thought process
• mental health issues
• special treatment procedures
• rehabilitation potential
• activities and interests

This initial assessment must be completed by the home 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 if the assessment should be kept in the resident’s medical record. Residents an their authorized representatives have a right to review the assessment and other medical records.

Using the information collected in the assessment process, the home then develops a written care plan. Just like the assessment process, several different departments within the home (your physician, nursing, the social worker, dietary, and others as needed) ought to participate in developing the care plan.

Care plans in all Michigan 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 seven days after the assessment is completed. Care must be provided in a way that prevents any decline in a resident’s abilities or conditions unless the decline cannot be prevented due to illness.

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

Care conferences 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 conference should be scheduled as needed, but at least once 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 conferences if their home does not routinely ask then to attend.

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

For help in making a care conference productive, call your local Ombudsman Office.

Assessment and care planning are critical to residents for good nursing home care. Done properly, both help to improve the quality of care and quality of life for the residents of 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.

Rev: 08/99, 10/00, 04/05