ࡱ>  bjbj>> "TTdppDJl;`J+::+:+:+6 @LEJ]L]L]L]L]L]L]adL]tH55tHtHL]:+:+F _VVVtH:+:+J]VtHJ]VV: [,[:+^Ms I6[ 6] `0;`@[ROeI. Oe[Oe[tHtHVtHtHtHtHtHL]L]VtHtHtH;`tHtHtHtHOetHtHtHtHtHtHtHtHtHp :  The Negotiated Care Plan is required by WAC 388-76-10355 and other applicable regulations. You are required to be familiar with and to follow all applicable laws and rules. This example is given to you to assist your compliance with the laws and regulations, but is not law or rule itself. All example text in this sample is provide for illustrative purposes only and should not be depended on to develop Negotiated Care Plans for your residents. RESIDENT NAME  FORMTEXT      PROVIDER NAME  FORMTEXT      CURRENT DATE  FORMTEXT      DATE ENTERED  FORMTEXT      DATE DISCHARGED  FORMTEXT      DATE OF BIRTH  FORMTEXT      AGE  FORMTEXT      SSN  FORMTEXT      PRIMARY LANGUAGE  FORMTEXT      NAME & ADDRESS OF INTERESTED PARTY (GUARDIAN, POA, FAMILY)  FORMTEXT      HOME PHONE  FORMTEXT      WORK PHONE  FORMTEXT      NAME OF PHYSICIAN OR MEDICAL GROUP  FORMTEXT      PHONE  FORMTEXT      FAX  FORMTEXT      PHARMACY NAME  FORMTEXT      PHONE  FORMTEXT      FAX  FORMTEXT      NAME OF DENTIST OR DENTAL GROUP  FORMTEXT      PHONE  FORMTEXT      FAX  FORMTEXT      ADVANCE DIRECTIVE  YES  FORMCHECKBOX NO  FORMCHECKBOX IF YES, SPECIFY TYPE(S)  FORMTEXT      LEGAL DOCUMENTS YES  FORMCHECKBOX NO  FORMCHECKBOX IF YES, SPECIFY TYPE(S)  FORMTEXT      CURRENT MEDICAL STATUS:  FORMTEXT       MEDICAL HISTORY:  FORMTEXT       YESNOCOMMENTSSPECIALTY NEEDS  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      DEMENTIA  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      MENTAL HEALTH  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      DEVELOPMENTAL DISABILITY FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       EMERGENCY EVACUATIONYESNOINDEPENDENTResident is Physically & mentally capable of safely getting out of the home without the assistance of another individual or the use of mobility aids. (The resident is considered independent if capable of getting out after one verbal cue) FORMCHECKBOX  FORMCHECKBOX ASSISTANCE REQUIREDResident Is not physically or mentally capable of getting out of the house without assistance from another individual or mobility aids. FORMCHECKBOX  FORMCHECKBOX SPECIAL INSTRUCTIONS:  FORMTEXT        CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWCOMMUNICATION: SPEECH/HEARING/VISION  Yes NoNegotiated Care Plan 388-76-10355 Problems with speech Describe:  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Explain how the resident is able to manage these areas. Do they wear glasses or need assistance when using the phone? Is their primary language something other than English? Explain how caregivers assist the resident with this task. You may write something such as after dressing, help Mrs. Jones put in her hearing aids in before she leaves her room for breakfast. Explain how the caregivers will communicate with the resident or how the resident makes him/herself understoodHearing problems Describe/aid:  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Visual problems Describe/aid:  FORMTEXT        FORMCHECKBOX  FORMCHECKBOX Telephone Use  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  DependentLanguage:  FORMTEXT       Describe MEDICATION MANAGEMENT: Self Administration (Check all that apply) Medications WAC 388-76-10430 through 388-76- 10490 FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers FORMCHECKBOX  Sprays  FORMCHECKBOX  Injections  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Keep Own MedsIs the resident able to self-administer any medication? They may use a medication such as an inhaler by themselves but other medications are administered by a caregiver. List the medications, if any, the resident uses on their own. Are there any directions on how the resident takes their own medication? You may state that a caregiver will ask the resident if they need assistance or check to see if a medication is running low. Does the residents ability fluctuate and they need to be monitored for change? SELF MEDICATION W/ASSISTANCE 388-76-10445 FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers FORMCHECKBOX  Sprays  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Meds Organizer  FORMCHECKBOX  Equipment:  FORMTEXT       Is the resident able to put their medication in their mouth but needs a caregiver to bring it to them? Maybe they use eye drops and need a caregiver to hold the dropper steady but they are able to expel the drops. How does this happen. Explain the routine for this resident. This is where you put the details of how the medication/s are given. You may say Mrs. Jones is to have 1 drop of prescription XYZ in her left eye twice daily. Bring the bottle to her and help her steady it above her eye while she squeezes the bottle. Monitor and report any changes to her doctor and her daughter. Order medication when it is running low. CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWADMINISTRATION388-76-10455Nurse Delegated?  FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers  FORMCHECKBOX  Sprays  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Meds Organizer  FORMCHECKBOX  Equipment:  FORMTEXT       If a resident requires you to put medication in their mouth or is unaware they are taking medication, then this is administration. Residents will likely require nurse delegation to have a medication administered by caregivers unless the task is done by a family member. An example of a task that may be delegated is insulin injections that the resident is unable to do on their own. Explain how the medication is administered. Is the task delegated? Maybe a family member completes the task. If a medication has to be prepared, explain how that is done here. For more information on nurse delegation see WACs 246-840-910 through 246-840-970 Injections  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes:  FORMCHECKBOX  Surrogate  FORMCHECKBOX  By family  FORMCHECKBOX  Licensed professional Medication plans when resident not in home: Explain what the plan is for the resident to get their medication when they are away from the home. TREATMENT/PROGRAMS/THERAPIESExplain if the resident receives any therapies or treatments. For example a resident may use oxygen or receive PT/ OT or wound care. Explain any needs listed in the assessment here. If there is a new treatment or therapy prescribed after the assessment, write it in and be sure to note the start date or end date if there is one. What is the residents assessed need to use the piece of equipment? What are the residents needs around pain control? Is the resident on hospice? If so, what is the hospice plan? 388-76-10355 (10) Does the resident require wound care? Explain how the therapy or treatment happens. If it is a caregiver helping with something provide directions on how to complete the task here. If the resident receives home health or some other kind of treatment from an outside source explain how that happens here so your caregivers know what to expect. Has a risk assessment been done to ensure this is safe for this particular resident? See WAC 388-76-10650 for more information. How do caregivers monitor or help the resident use the equipment safely? Health issues to monitor:YesNoOxygen Use FORMCHECKBOX  FORMCHECKBOX Pain FORMCHECKBOX  FORMCHECKBOX Weight Loss/Gain FORMCHECKBOX  FORMCHECKBOX Programs the resident attends, such as adult day health Nursing Consultation/TreatmentsYesNoRN Delegation FORMCHECKBOX  FORMCHECKBOX What tasks:  FORMTEXT       Consent  FORMCHECKBOX  FORMCHECKBOX Physical Enablers: Does the resident use any assistive devices such as bedrails, trapeze, transfer pole, walker, wheelchair, etc.?  CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWPSYCH/SOCIAL/COGNITIVE STATUSYesNoWhat resident does Describe behaviors be specific: Some of these will be listed in the residents assessment but others will develop over time. Be sure to have current information listed for behaviors. If a behavior is no longer happening, be sure to say so. See WAC 338-76-10355 (7)(a): It requires that a plan to be developed and followed in the case of a foreseeable crisis due to a residents assessed needs. Describe specific non-medication (behavioral/environmental) interventions to address the symptoms: What is it that a caregiver can do to address the behaviors a resident is displaying? Document any non-medication interventions that she/he should attempt prior to giving a resident a medication (if prescribed as needed or PRN You may say something such as Mrs. Jones is often tearful at night. Speak to her gently and reassure her she is safe. Give her time to express herself and listen to her concerns. If she continues to be tearful she may have XYZ to help her sleep. If the behavior continues, contact her doctor and her daughter. Sleep disturbance FORMCHECKBOX  FORMCHECKBOX Memory impairment (Short-term) FORMCHECKBOX  FORMCHECKBOX Memory impairment (Long-term) FORMCHECKBOX  FORMCHECKBOX Decision making FORMCHECKBOX  FORMCHECKBOX Disruptive behavior FORMCHECKBOX  FORMCHECKBOX Assaultive FORMCHECKBOX  FORMCHECKBOX Resistive FORMCHECKBOX  FORMCHECKBOX Depression FORMCHECKBOX  FORMCHECKBOX Anxiety FORMCHECKBOX  FORMCHECKBOX Disorientation FORMCHECKBOX  FORMCHECKBOX Wandering in home FORMCHECKBOX  FORMCHECKBOX Exit seeking FORMCHECKBOX  FORMCHECKBOX Hallucinations FORMCHECKBOX  FORMCHECKBOX Delusions If yes, describe: FORMCHECKBOX  FORMCHECKBOX Requires psychopharmacological medications If yes, describe symptoms for each medication:  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX UNIVERSAL PRECAUTIONS FORMTEXT      Caregiver will use latex/plastic gloves when in contact with any secretions to prevent spread of infection. Thorough hand washing with soap will be done before and after gloving. Gloves will be put on and discarded at the end of each task. CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWMOBILITY In room & immediate living environment:  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  DependentExplain how the resident gets around. Do they walk independently or with assistance? Do they use a walker or a cane or are they wheelchair bound? What does their assessment say and what is happening currently? Be sure to document any changes and any discrepancies between the NCP and the assessment. If there is a fall prevention plan explain it here. What do caregivers do to help the resident get around? Do they provide a one person assist when walking or remind them to use their walker?Outside of immediate living environment (to include outdoors):  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Risk for falls: Equipment:  FORMTEXT       Preferences/Choices:  FORMTEXT       BED MOBILITY/TRANSFER  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent How does the resident reposition themselves in bed? Do they require assistance or turning on a schedule? Do they have special equipment or procedures such as bridging to prevent bed sores? If the resident uses a bedrail, trapeze or transfer pole, has there been an assessment completed to explain the dangers to the resident and or their family? This assessment must be in the residents file. See WAC 388-76-10650Specifically, what will the caregiver need to do to help this resident while they are in bed? If any specialized equipment is used to help the resident transfer, how is it used? Is the resident a fall risk and if so, what is being done to prevent falls? Skin care due to inability to position self:  FORMTEXT      Equipment/supplies:  FORMTEXT       Preferences:  FORMTEXT      Enablers:  FORMTEXT       Safety assessment, alternatives explored; how to keep resident safe:  FORMTEXT       Night time care needs:  FORMTEXT       EATING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent What kind of food does the resident like to eat? Do they have a special diet prescribed by their doctor? Do they need assistance eating or monitoring for choking? Do they require a soft diet or have any allergies? What does the caregiver do to help the resident eat? Do they prepare meals or ask the resident what his/her preferences are? Do they provide assistance and if so, how? If a resident receives a supplement shake make sure they have been approved by the residents doctor first.Special diet/supplements:  FORMTEXT       Eating habits  FORMTEXT       Food allergies  FORMTEXT      Preferences/equipment  FORMTEXT      CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWTOILETING/CONTINENCE ISSUES  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Explain what needs to be done to toilet the resident. Can he/she assist in the process? How does the resident prefer to toilet (bedside commode, bathroom)? Does the resident require special equipment such as a Hoyer? If incontinent, how often? Does the resident wear incontinent care products, or does he/she prefer to wear clothes and change if wet? Does the resident have a potential for skin breakdown due to incontinence? Can the resident complete his/her own incontinent care? If resident can assist with peri care, what can he/she do?What does the caregiver need to do to help? How many caregivers should assist? Does the caregiver need to remain with the resident in the bathroom for safety? If required, how should the caregiver use special equipment such as a hoyer? How often should the resident be toileted? For incontinent residents how should caregivers protect the resident skin? Is there a barrier cream? A particular way to cleanse the area? How often should the client be cleaned and changed? If a resident has a special request such as do not disturb during the night make a note here for caregiving staff. Bladder incontinence  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Occasional Bowel incontinence  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  OccasionalSkin care due to bowel/bladder incontinence:  FORMTEXT      Equipment:  FORMTEXT       Preferences:  FORMTEXT       DRESSING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent What assistance does the resident require for dressing? Can he/she complete the task by themselves? Does he/she require stand by, minimal, total assist? Does the resident have special equipment (shoe horn, grabber device)? Does he/she require set up of these items for use?If the resident requires assist, how many staff is needed? If the resident requires set up, should the staff stay in the room or just check on the resident periodically? What does the caregiver do to help the resident dress? Make a note of any special preferences resident has, such as  no sweatpants,  likes to wear sweater at all times Equipment:  FORMTEXT       Preferences:  FORMTEXT        PERSONAL HYGIENE  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent What can the resident do when brushing teeth, cleaning dentures, brushing hair, washing face, grooming self, shaving? Can resident do tasks independently if needed items are set up? What will staff need to do to assist resident with brushing hair, brushing teeth, cleaning dentures, shaving, putting on makeup? Do staff set up items and cue resident or do staff complete the task for the resident? Does resident have beard or moustache they want to keep? How will staff assist in grooming facial hair if resident does not want it shaved off? Does resident have any special personal care items he/she likes to use (favorite shaving cream, certain type of brush, favorite toothpaste)? Who will provide this if it is not an item normally offered by the facility?Oral hygiene, including dentures:  FORMTEXT       When and how often:  FORMTEXT       Preferences:  FORMTEXT        BATHING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Will resident prefer a bath or a shower? How often does resident prefer to bathe? Can resident do own bedside bath between routine showers?How will staff assist with bathing? Stand by assist, total assist, wash resident back but allow resident to do everything else? Does the staff person need to be in the bathroom while resident is in shower/bath How many times a week will the staff assist the resident with bathing? Include any special equipment staff will use such as shower chairs, transfer board, equipment to help resident reach feet or back , etc. How often:  FORMTEXT       When:  FORMTEXT       Equipment:  FORMTEXT       Preferences:  FORMTEXT        CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWBODY CARE (Foot care, skin care, nail care, range of motion, dressing changes)  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent What are the residents needs for body care? For example, if they are assessed as having dry skin and they need to have lotion applied after each bath or incontinence episode, document it here. They may need to have a medication applied. If so, is there nurse delegation in place? Also, the resident may have dry skin and requires lotion, but they are able to apply it themselves. Be sure to say how this activity takes place. If the resident is diabetic? What is the plan around foot care?If the resident has needs around body care, what are caregivers expected to do to help them? For example, this may say something like apply lotion to arms and legs after each bath.  Foot care:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Skin care:  FORMCHECKBOX  Yes  FORMCHECKBOX  No How often:  FORMTEXT       Skin problems:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Describe:  FORMTEXT      Dressing changes:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Nurse delegated:  FORMCHECKBOX  Yes  FORMCHECKBOX  No & , . 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Is the resident working on a money management program with a goal of independence?What will the staff do to assist the resident in managing the finances? If the home manages the residents funds, how will this be managed and monitored? How will the resident access funds if he/she needs petty cash or needs a bill paid? If the facility doesnt manage the resident funds, how will the facility make sure resident can access funds in a timely fashion if he/she was to go on an outing or purchase items? How will the facility assist the resident in keeping the funds/checkbook/bank statements/etc. safe? SHOPPING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Special transportation needs:  FORMTEXT       How often:  FORMTEXT       Preferences:  FORMTEXT       How does the resident do their personal shopping? They may like to go with a family member or purchase special items. Generally speaking, the AFH will provide most of the shopping for food, toiletries, etc. but some residents or their families may do some shopping. Explain how this happens for the resident. TRANSPORTATION  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Medical services: Special transportation needs:  FORMTEXT       Equipment:  FORMTEXT       How often:  FORMTEXT       Preferences:  FORMTEXT       What are the resident s transportation needs? Do they have a standing appointment or require special transportation? Generally speaking, the AFH is not required to provide transportation for residents. You do, however, need to coordinate transportation for the resident. Explain how transportation happens for the resident. For example, their family member may transport to Dr. appointments or they may use medical transportation services. ACTIVITIES/SOCIAL NEEDS  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Interests/Activities/Religious Activities:  FORMTEXT       Social/Cultural Traditions/Preferences:  FORMTEXT       Family/Friends/Relationships:  FORMTEXT       Employment Support:  FORMTEXT       Clubs/Groups/Day Health: Emergency Numbers Provided:  FORMTEXT       Special Arrangements:  FORMTEXT       Participation Issues:  FORMTEXT       What activities does the resident like? Do they go to church on Sunday or meet with family at a particular time? Do they enjoy sitting outside or playing cards? What do caregivers do to assist the resident in their activities? Do they set up transportation or facilitate an activity? The directions may read something like Make sure Mrs. Johnson is up, showered and dressed for church on Sundays by 9:45. SMOKING  FORMCHECKBOX  Yes  FORMCHECKBOX  No Safety Concerns:  FORMTEXT       Preferences:  FORMTEXT       Does the resident smoke? If so are they safe to smoke independently?Do caregivers need to provide any assistance or supervision with smoking? CASE MANAGEMENT  FORMTEXT       Does the resident have a case manager? If so, are they with DDA, RSN, HCS?Contact the case manager when: The resident needs assistive device or other services to meet the needs When you need help with the care plan Significant changes with the condition/needs that necessitate changes with the care plan OTHER ISSUES/CONCERNS/PROBLEMS  FORMTEXT        FORMTEXT       FORMTEXT       WAC 388-76-10355 through 388-76-10385 - Negotiated Care Plan. Brief instructions based on WAC Developed within 30 days of admission based on the Assessment and the Preliminary Service Plan. 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Designed to meet the Residents Needs, Preferences, and Choices. Developed with input from the Resident and/or the Residents Representative / Surrogate Decision Maker, appropriate professionals, and the case manager, if applicable Agreed to, Signed and Dated by the Resident and/or the Residents Representative / Surrogate Decision Maker, appropriate professionals, and the provider. The signed copy of the plan must be given to the Case Manager if Resident is receiving services paid for fully or partially by the department. Reviewed and Revised: (a) at least every 12 months; (b) upon any significant change in Residents physical or mental condition; and (c) upon resident request. DATE OF ORIGINAL PLAN:  FORMTEXT       TITLE/TYPESIGNATUREDATEREVIEW/REVISE DATEREVIEW/REVISE DATEPROVIDER  FORMTEXT       RESIDENT  FORMTEXT       RESIDENT REPRESENTATIVE  FORMTEXT       RESIDENT REPRESENTATIVE  FORMTEXT       SURROGATE DECISION MAKER  FORMTEXT       CASE MANAGER  FORMTEXT       SOCIAL WORKER  FORMTEXT       HEALTH PROFESSIONAL  FORMTEXT       OTHER:  FORMTEXT       OTHER:  FORMTEXT        The person signing writes the date s/he actually read and agreed to the plan. If the participant has verbally agreed to the plan, the provider should note below: (a) the name and role of the participant; (b) the date the participant had the plan read to them; and (c) what if any changes the participant recommended for the plan.  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