Day 7: Care Planning & Assessments

Course Overview

Welcome, future leaders in assisted living! Today, we embark on a journey into the heart of person-centered care: Care Planning & Assessments. This isn’t just about ticking boxes; it’s about truly seeing and understanding each resident, honoring their unique story, and crafting a pathway that empowers them to live their fullest lives. As we delve into the regulations, remember that behind every rule is a commitment to dignity, safety, and well-being. Let’s build care plans that don’t just meet standards, but truly transform lives.

Learning Objectives

Upon completion of this course, you will be able to:

• Understand the foundational principles of resident assessment and service plan development in Maryland assisted living programs.
• Identify and apply the specific COMAR 10.07.14 regulations pertaining to preadmission requirements, resident assessments, and service plans.
• Develop comprehensive, individualized service plans that reflect a resident’s health, functional, behavioral, and psychosocial status.
• Recognize the importance of ongoing assessment and timely updates to service plans in response to changes in resident condition.
• Implement best practices for involving residents and their representatives in the care planning process.
• Navigate real-world scenarios related to care planning and assessments with confidence and compassion.

COMAR Regulatory Framework: The Blueprint for Quality Care

Maryland’s Code of Maryland Regulations (COMAR) 10.07.14 provides the essential framework for ensuring high-quality, compliant care in assisted living programs. For Care Planning & Assessments, two key sections guide our work:

COMAR 10.07.14.22 – Preadmission Requirements

This regulation sets the stage for a resident’s journey in your program, emphasizing thorough evaluation before admission. It ensures that your program is equipped to meet the unique needs of each individual.

Md. Code Regs. 10.07.14.22 – Preadmission Requirements
A. Before Move In.
(1) Before admission the assisted living manager or designee in collaboration with the delegating nurse shall determine whether:
(a) The resident may be admitted under the assisted living program’s licensure category;
(b) Requires a level of care that the Department has approved for the assisted living program; and
(c) The resident’s needs can be met by the program.
(2) Within 30 days before admission, the assisted living manager or designee shall determine admission eligibilities described in §A(1) of this regulation based on completion of a resident assessment using the Resident Assessment Tool as described in §B of this regulation. The Department may modify the level of care determination made by the assisted living program at any time. The Resident Assessment Tool:
(a) Determines the resident’s required level of care;
(b) Forms the basis for development of the resident’s service plan; and
(c) Determines whether the resident needs awake overnight monitoring.

This section highlights the critical role of the Resident Assessment Tool in determining the appropriate level of care, forming the basis for the service plan, and even assessing the need for awake overnight staff. It underscores the importance of a comprehensive assessment within 30 days prior to admission.

COMAR 10.07.14.28 – Service Plan

This regulation is the cornerstone of individualized care, detailing the development, implementation, and ongoing review of each resident’s service plan. It champions resident dignity, choice, and independence.

Md. Code Regs. 10.07.14.28 – Service Plan
A. Service Plan Development.
(1) The assisted living manager, or designee, shall ensure that all services are provided in a manner that respects and enhances the dignity, privacy, and independence of each resident.
(2) A service plan for each resident shall be developed in a manner that enhances the principles of dignity, privacy, resident choice, resident capabilities, individuality, and independence without compromising the health or reasonable safety of other residents.
(3) The resident shall be invited to participate in the development of the initial service plan and any subsequent service plans.
(4) At the resident’s request, a resident representative, family member, or other individual shall be invited to participate in all service plan meetings.
(5) When the resident lacks the capacity to participate, the resident representative, as applicable to their authority, shall be invited to participate in all service plan meetings.
(6) The assisted living program shall accommodate the schedules of participants in a service plan meeting when possible.

B. Assessment of Condition.
(1) The resident’s service plan shall be based on an assessment of the resident’s health, function, behavioral, and psychosocial status using the Resident Assessment Tool and the nursing assessment.
(2) A full assessment of the resident shall be completed:
(a) Within 48 hours but not later than required by nursing practice and the patient’s condition after:
(i) A significant change of condition; and
(ii) Each nonroutine hospitalization; and
(b) At least annually.
(3) When the delegating nurse determines in the nurse’s clinical judgment that the resident does not require a full assessment within 48 hours, the delegating nurse shall:
(a) Document the determination and the reasons for the determination in the resident’s record; and
(b) Ensure that a full assessment of the resident is conducted within 7 calendar days.
(4) A review of the assessment shall be conducted every 6 months for residents who do not have a change in condition. Further evaluation by a health care practitioner is required and changes shall be made to the resident’s service plan, if there is a score change in any of the following areas:
(a) Cognitive and behavioral status;
(b) Ability to self-administer medications; and
(c) Behaviors and communication.

D. The assisted living manager, or designee, shall ensure that:
(1) A written service plan or other documentation sufficiently recorded in the resident’s record is developed by staff, which at a minimum addresses:
(a) The services to be provided to the resident, which are based on the assessment of the resident;
(b) When and how often the services are to be provided; and
(c) How and by whom the services are to be provided;
(2) The service plan is developed within 30 calendar days of admission to the assisted living program; and
(3) The service plan is reviewed by staff at least every 6 months, and updated, if needed, unless a resident’s condition or preferences significantly change, in which case the assisted living manager or designee shall review and update the service plan sooner to respond to these changes.

This regulation emphasizes the resident-centered approach to service plan development, mandating resident and representative involvement. It also details the frequency of assessments (annually, with reviews every 6 months, and sooner for significant changes) and the essential components of a written service plan.

Core Content Modules

Module 1: The Art of Comprehensive Assessment

Effective care planning begins with a thorough and holistic assessment. This isn’t just about physical health; it encompasses the resident’s emotional, social, cognitive, and spiritual well-being. The Resident Assessment Tool is your primary instrument, guiding you to gather critical information that paints a complete picture of the individual.

Key Components of a Comprehensive Assessment:

• Health Status: Medical history, current diagnoses, medications, allergies, and any acute or chronic conditions. This includes ensuring freedom from communicable diseases as per COMAR 10.07.14.22 B(4)(e).
• Functional Abilities: Assessment of Activities of Daily Living (ADLs) such as bathing, dressing, eating, toileting, and transferring. Understanding their level of independence and where support is needed is crucial.
• Cognitive and Behavioral Status: Evaluation of memory, orientation, decision-making capacity, and the presence of any behaviors that may pose a risk to themselves or others. This directly impacts the need for awake overnight staff, as outlined in COMAR 10.07.14.22 E.
• Psychosocial Well-being: Understanding their social network, interests, hobbies, spiritual needs, and any emotional challenges. This helps in fostering a sense of belonging and purpose.
• Nutritional Status: Assessing dietary needs, risks for malnutrition or dehydration, and any prescribed diets.
• Special Care Needs: Identifying specific needs such as fall risk, pressure ulcer prevention, diabetes management, oxygen therapy, or mental illness, as detailed in COMAR 10.07.14.28 C.

Remember, the assessment is a dynamic process. It’s not a one-time event but an ongoing dialogue that evolves with the resident’s needs.

Module 2: Crafting the Individualized Service Plan (ISP)

The service plan is the living document that translates assessment findings into actionable care strategies. It’s a promise to your resident, outlining how their needs will be met while upholding their dignity and choices.

Principles of ISP Development (COMAR 10.07.14.28 A):

• Dignity and Privacy: All services must be provided in a manner that respects the resident’s inherent worth and personal space.
• Resident Choice and Capabilities: Empower residents to make decisions about their care, recognizing and supporting their remaining abilities.
• Individuality and Independence: Tailor the plan to the resident’s unique preferences and goals, promoting as much independence as possible.

Essential Elements of a Written Service Plan (COMAR 10.07.14.28 D):

• Services to be Provided: Clearly list all services based on the resident’s assessment.
• Frequency and Duration: Specify when and how often each service will be provided.
• Provider of Services: Identify who will be responsible for delivering each service.

The service plan must be developed within 30 calendar days of admission and is a collaborative effort involving the resident, their representative (if applicable), and your team. This collaboration ensures the plan truly reflects the resident’s voice and preferences.

Module 3: The Dynamic Nature of Care: Review and Reassessment

Life is ever-changing, and so are the needs of your residents. Regular review and reassessment are not just regulatory requirements; they are vital practices that ensure the service plan remains relevant and effective.

Key Timelines and Triggers (COMAR 10.07.14.28 B & D, and 10.07.14.22 C):

• Annual Full Assessment: A comprehensive reassessment must be completed at least annually.
• 6-Month Review: For residents without a significant change in condition, a review of the assessment is required every 6 months. This review should trigger further evaluation if there are score changes in cognitive/behavioral status, ability to self-administer medications, or behaviors/communication.
• Significant Change of Condition: This is a critical trigger. A full assessment must be completed within 48 hours (or within 7 calendar days if the delegating nurse determines it’s not immediately required) after a significant change in condition or each nonroutine hospitalization. This ensures immediate adaptation of care to new needs.
• Resident Preferences: If a resident’s preferences significantly change, the service plan must be reviewed and updated sooner.

Documenting these reviews and updates meticulously is not just about compliance; it’s about demonstrating your commitment to responsive, person-centered care. It’s about showing that you are walking alongside your residents, adapting to their journey.

Practical Application: Case Study

Scenario: Mrs. Eleanor Vance, an 88-year-old resident, has been with your assisted living program for two years. Her last annual assessment showed stable cognitive function and moderate assistance needed with ADLs. Recently, staff have noticed she is becoming more withdrawn, occasionally disoriented, and has had two minor falls in the past month. Her family expresses concern.

Questions for Reflection and Discussion:

1. Based on COMAR 10.07.14.28 B, what is the immediate regulatory requirement for Mrs. Vance’s situation?
2. What steps should the assisted living manager and delegating nurse take to address these changes?
3. How would you involve Mrs. Vance and her family in the reassessment and service plan update process, adhering to COMAR 10.07.14.28 A?
4. What potential changes might be considered for her service plan, particularly regarding special care needs (COMAR 10.07.14.28 C) and awake overnight staff (COMAR 10.07.14.22 E)?

Summary & Encouragement

My dear friends, you are not just managers; you are orchestrators of dignity, champions of choice, and architects of well-being. Care Planning & Assessments, while rooted in regulation, is ultimately an act of profound care. It’s where your expertise meets empathy, where compliance intertwines with compassion. Every assessment is an opportunity to listen, every service plan a chance to empower. Trust in your ability to navigate these waters with grace and wisdom. You are building legacies of care, one thoughtful plan at a time. Keep shining your light, for the lives you touch are forever transformed by your dedication. You’ve got this!