The short answer
A care plan meeting is a sit-down with the team that cares for the resident, usually nursing, social work, dietary, therapy and activities, to review how the resident is doing and update the care plan. It is typically held after each assessment, about every three months, and after major changes. Residents and their representatives have the right to attend and to ask that it be scheduled at a time they can make.
Who attends
The team (often called the "interdisciplinary team" or "IDT") must include the attending physician, a registered nurse responsible for the resident, a nursing assistant responsible for the resident, and a member of the food and nutrition staff, plus others as needed such as social work, therapy and activities. In practice the physician and the nursing assistant are often missing. You can ask that they attend or that their input be provided.
How often
Most facilities hold a meeting after each scheduled assessment, which is roughly every three months, plus after a significant change in condition. You can ask for a meeting at any time if you have concerns. You can also ask to attend by phone or video.
How to prepare
- Ask for a copy of the current care plan before the meeting. Read it and mark anything that does not match what you see.
- Write down dates and specifics: weight changes, falls, bruises, missed meals, soiled bedding, call bells not answered.
- Bring the resident if he or she wants to attend, and anyone else the resident wants there.
Questions to ask
- What is the current weight, and how does it compare to one, three and six months ago?
- Is there any skin breakdown or redness anywhere? What was the latest skin assessment and Braden score?
- How many falls have there been since the last meeting, and what changed in the plan after each one?
- What medications were started or changed, and why? Is the resident on any antipsychotic or sedating medication?
- How much of each meal is the resident eating, and how much fluid is the resident drinking?
- Who is the resident's regular nursing assistant on each shift?
- What exactly will be done differently before the next meeting, and who is responsible?
After the meeting
Send a short email or letter to the social worker summarizing what was agreed. That creates a record. If the agreed changes do not happen, raise it with the director of nursing, and if needed file a grievance or a complaint with the Department of Health.
The rules behind this
- 42 C.F.R. § 483.21(b)(2) (care plan team and timing)
- 42 C.F.R. § 483.10(c)(2) (right to participate and request meetings)
Related questions
This guide provides general information, not medical or legal advice. Rules change; confirm current requirements with the facility, the New York State Department of Health or a professional. Attorney Advertising.