Service Plans
When a person begins to receive long-term care services, an assessment determines their support needs. The care team (including the client) uses the assessment to develop a service plan or negotiated care plan. This plan gives you information about the client and instructions for your caregiving responsibilities.
All service plans include details about the client and the care that you will provide, such as:
the client’s preferences about care, activities,
and other personal issues;
- the client’s condition, special needs, behavioral symptoms, and/or diseases;
- when and how you will provide assistance based on the client’s needs, health, preferences, and safety;
- how the client’s medication is managed; and
- how the client communicates.
The service plan might also include contact information for care team members or the client’s advance directives.
Level of Support
Every client needs a different level of support with personal care tasks. The list of tasks and amount of
support that the client’s needs are included in their service plan.
If your client has a DSHS CARE plan (assessment details and service summary), it will tell you how much support the client needs to complete each task safely. There are five levels of support in a DSHS CARE plan:
- Independent: There are no safety concerns, and the client does not need any help or reminders with this specific task.
- Supervision: The client can complete the task safely, but you will monitor to make sure. You may need to remind the client or coach them as they complete the task. Supervision does not include any hands-on support.
- Limited Assistance: The client is highly involved in the task but needs some hands-on assistance. You might help guide their hands or arms as they complete the task. Limited Assistance does not include any weight-bearing support.
- Extensive Assistance: The client needs weight-bearing support or full assistance during parts of the task. You will need to support the client’s weight or complete parts of the task for them.
- Total Dependence: The client is unable to participate in any part of the task. You will need to do all parts of the task for the client.
These levels of support are specific to DSHS. Levels of support may vary depending on your care setting and the service plan tools it uses.
Check the Service Plan
See the example DSHS CARE plan (Assessment Details and Service Summary) in the Resource Directory on page 280. What level of support does the client require for toilet use?
See the example Negotiated Service Agreement in the Resource Directory on page 303. How is the explanation of needs and preferences about toileting different from the DSHS CARE Plan?
Service Plans and Care Settings
The service plan may have a different name in your care setting. Some other names are “negotiated care plan”, “negotiated service agreement,” “care plan,” or “plan of care.”
Where you can find the service plan also depends on your care setting. Adult family homes, assisted living facilities, and enhanced services facilities usually keep the service plan in the resident’s chart. If your workplace has electronic health records, the service plan may be available on a tablet or computer. If you support someone in their home, you might only receive a list of tasks.
Where can you find the service plan for a person you support in your workplace?
Understanding Client Preferences
People have the right to make choices about the care they receive. No service plan has all the details you will need to provide appropriate support. You must also communicate with the client about each task you do.
The service plan is only a document, and the client’s needs and preferences may change over time. Communicate with the client regularly to make sure you are supporting them in the way they prefer. Document and report any changes.
Communicating with the Client
Some clients have difficulty speaking, do not speak at all, or use other ways to communicate (sign language, assistive devices, or gestures). The service plan has information about how you can understand and be understood by the client. Your supervisor or employer is also a good resource for how best to communicate with the client. If the client has a guardian or power of attorney, that person has the authority to communicate and make decisions for the client. The alternate decision maker’s contact information should be listed in the care plan.
A client who has a guardian or Power of Attorney still has the right to make choices when able.