Changing or Updating the Life Plan
Whether the Life Plan needs to be updated depends on the nature of the change. Care Managers continually review the individual’s preferences, goals, and needs for supports and safeguards. Care Managers must evaluate whether there is a need to update the Life Plan when an individual’s circumstances change.
Immediate changes to the Life Plan
If there is a sentinel event, the Care Manager must immediately change the person’s Life Plan and communicate the change to the individual and his/her care planning team. Sentinel events include but are not limited to: accidents or events resulting in serious personal injury, major medical events, a major psychiatric event or decompensation resulting in extended inpatient psychiatric hospitalization; and/or significant changes or improvement in behavior or physical functioning.
Non-immediate changes to the Life Plan
There may be a change to the person’s health and safety that are not a sentinel event, as described in the paragraph above. These changes to the individual’s health and safety support needs must be met immediately by providers and communicated effectively to the Care Manager and support providers. While an immediate change to the Life Plan is not required, the Care Manager should document the communication in his/her care management notes. The Care Manager may update the person’s Life Plan at the regularly scheduled Life Plan Review meeting.
No Life Plan change required
Temporary changes, such as those related to an illness, do not require a Life Plan change. However, temporary changes may need to be communicated timely to the Care Manager, providers, and care planning team. Temporary changes may also be documented in the care management notes.
A sentinel event is an unanticipated event including:
- Accidents or events resulting in serious personal injury
- A major medical event
- Major psychiatric event or decompensation resulting in extended inpatient psychiatric hospitalization
- Significant improvement in behavior or physical functioning
Sentinel events would necessitate changes or updates to the Life Plan.
Short-Term Support Needs
Acute events like monitoring after sedation, flu or short-term illness do not require a Life Plan change because of the limited temporary nature.
these do require staff education for monitoring of health and safety through day-to-day documentation.