Assessment & Care Planning

The Key To Good Care

A Guide for Nursing Home Residents and Their Families

Why do we need to know about Assessment and Care Planning?
To give good care, nursing homes need to know each person's strengths, needs, interests, and routines. Staff can prevent residents from losing abilities by keeping them active and mobile, knowing their habits and needs. Through assessment, staff learn about residents and their care needs. Resident/family involvement in care planning can help make sure residents get good care.

What is a Resident Assessment?
Assessments are a way to gather information about how well people are able to take care of themselves and in what areas they need help.  Staff ask about residents' "functional abilities" - how well they walk, talk, eat, dress, bathe, see, hear, communicate, understand and remember. Staff ask about residents' habits, activities and relationships so they can help residents live comfortably.

The assessment helps staff look for what is causing a problem. For instance, poor balance could be caused by medications, inactivity, weak muscles, poor-fitting shoes, or a urinary or ear infection.  Staff must know the cause in order to give treatment.

What is a Plan of Care?
A plan of care is a strategy for how the staff will help a resident.  It says what each staff person will do and when it will happen (for instance - The nursing assistant will help Mrs. Jones walk to each meal to build her strength).  Care plans must be reviewed regularly to make sure they work and must be revised as needed.  For care plans to work, residents must feel like they meet their needs and must be comfortable with them.  Care plans can address any medical or nonmedical problem (example:  incompatibility with a roommate).

What is a Care Planning Conference?
A care planning conference is a meeting where staff and residents/families talk about life in the facility - meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents/families can bring up problems, ask questions, or offer information to help staff provide care. Staff who work with a resident should be involved in the care plan conference - nursing assistants, nurse, physician, social worker, activities staff, dietitian, occupational and physical therapists.

When does a Care Planning Conference occur?
Care planning meetings occur every three months, and whenever a resident gets worse or better physically or mentally, in ability to function or need for help. The care plan must be completed within 7 days after an assessment. Assessments must be done within 14 days of admission and at least once a year. Some parts must be reviewed every three months, and whenever there is a big change that might require a more complete review or a change in care.

What should residents/families talk about at the meeting?
Talk about how the resident is feeling, ask questions about care and the daily routine. Talk about food, activities, interests, how the resident/family get along with staff, personal care, medications, how well the resident is getting around. Staff must talk to the resident/family about treatment decisions such as medications and restraints and can only do what is agreed to. You may have to be persistent in bringing up your concerns or making choices. If you run into problems, call your local "ombudsman" for help.

How residents and their families can participate in Care Planning:
Residents have the right to make choices about care, services, daily schedule and life in the facility, and to be involved in the care planning meeting. Participating is the only way to be heard.

Before the meeting the resident/family should:

  • Tell staff how you feel - your concerns; strengths, preferences, daily routines; what the resident can do and when they need help; how things are with family/friends.
  • Know about the resident's condition, care and treatment; if you need more information, ask the doctor or other staff.
  • Ask staff to hold the meeting when the family can come; if the resident wants them there.

During the meeting:

  • Discuss options for meeting the resident's needs and preferences.
  • Be sure you understand, and agree with the care plan and feel it meets the resident's needs.
  • Ask questions if you need terms or procedures explained to you.
  • Ask for a copy of the care plan; ask with whom to talk if it needs changes in it.

After the meeting:
Watch how the care plan is followed; talk with nurse aides/other staff about it.

Specifically for Families:
  • Remember - each resident has the right to make informed choices about care.
  • Support your relative's agenda and participation in the meeting.
  • Even if your relative has dementia, involve them in care planning as much as possible. Always assume that they may understand and communicate at some level.
  • Help the staff find ways to communicate with and work with your relative.
  • Help watch how the care plan is working and talk with staff if questions arise.

Principles for Care Planning - A Good Care Plan Should:

1.  Properly Identify the Problem: Watch for care plans that incorrectly label problems. These may limit residents' choices or their attempts to let their needs and feelings be heard as "problem behaviors."

2.  Be Specific and Individualized: Watch for care plans that have goals and approaches that are meaningless because they are too broad or are not individualized.

3.  Be Written in Common Language that Everyone can Understand: Watch for care plans written in professional jargon that is difficult to understand or implement.

4.  Have the Resident's Agreement: Watch for care plans that have problems that do not reflect the resident's concern or have solutions that will not work for the resident.

5.  Be Supportive of Residents' Well-being, Functioning and Rights: Watch for care plans that are for staff, not residents that cause anxiety to residents or do not adapt to residents' needs or say what the resident will do instead of what the staff will do.

6.  Utilize a Team Approach Based on Problems Identified in the Assessment: Watch for care plans that do not address needs identified in the assessment; contain conflicting goals; do not use referrals to other agencies or professionals as needed.

7.  Be Reevaluated and Revised Routinely: Watch for care plans that never change.

Care plan meetings may be helpful when:

  • Residents (and families) need information.
  • Residents (and families) have concerns about services or the resident's condition.
  • The facility is violating state or federal requirements.
  • The facility's complaint resolution process has failed.
  • A resident receives a discharge notice.
  • You want to bring several people together, each of whom has a role in the resident's care.
  • The facility proposes to use physical restraints or new medications.


 Northern Virginia
Long-Term Care
Ombudsman Program

12011 Government Center Parkway
Suite 708

Fairfax, VA 22035 

 Intake Line: 703-324-5861
 To request reasonable accommodations:
Call TTY 711 or 703-449-1186;
Fax 703-653-1796

8 a.m. to 4:30 p.m.

E-mail: NVLTCOP@FairfaxCounty.Gov


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