At the core of this standard is the need for facilities and care recipients to partner to develop a plan that focuses on optimising the health and wellbeing of the residents in line their needs, goals and preferences.
The planning of care is a dynamic process, as many changes will occur during a residents stay. A review of a resident's care needs may need to be undertaken when:
- the resident has a sudden change in their physical or psychological condition
- an incident occurs that places undue stress on the resident
- an adverse finding is made from a medical professional
- information is supplied by a resident representative or family member
What does this mean for you?
Facility owners and managers need to demonstrate they:
- Identify current and future needs
- Provide individualised service (including risk assessments & training)
- Ensure systems in place
- Provide documented evidences
To achieve this outcome an organisation must have an assessment and planning process that identifies residents’ current needs, goals and preferences, this includes those that may arise in the future, such as end-of-life planning. This plan is made available for all relevant parties to view and review regularly to reflect the changing needs of the resident.
Individualised service comes with an increase in risk. Each time a resident requests a change to their care plan, a risk assessment will need to be completed. Evidence of the assessment must be included in the resident’s care plan. This means organisations will have to implement a risk assessment framework and train staff on how to complete it when other parties (ie medical practitioners and service providers) need to provide input.
The quality agency will expect that an organisation:
Changes in care plans must be discussed in staff meetings so all staff are aware of what care needs have changed and what the impact is on them to implement the changes as expected.
Finally, there must be evidence that staff have been trained in these systems. This evidence, along with expected outcomes, must be accessible to authorised staff at all times.
Whilst not mentioned as part of the standard, it is important to remember that any changes in a resident’s care needs (i.e. those that relate to activities of daily living, behaviour or complex health care) could impact the funding the facility receives for that resident. All changes to care plans should be referred to your ACFI specialist so an ACFI review can be completed.