At the time of admission, a multi-disciplinary assessment is completed and a Plan of Care is formulated. Within the first eight weeks after admission, a care conference is held. The Care Plan is reassessed and revised at the conference and the Advanced Health Care Directive is reviewed by the multi-disciplinary team.
Thereafter, Care Conferences are held at least annually and offer an opportunity for all parties to communicate. Concerns or questions can be addressed to staff at any time. Staff continually evaluate and update the Plan of Care based on the resident’s status. Residents and Families are encouraged to be active participants in the assessment, planning and evaluation of care. The Resident and family may have access to the Care Plan under the supervision of the Charge Nurse.