Assessments and Support Plans


It is important to work as a TEAM. As a direct care staff person, you are one of the primary caregivers for the residents in your home. However, you are not alone. You are part of a care TEAM that must work together to provide the best possible care. The members of the care TEAM will vary depending on the size and organizational structure of the personal care home. At a very small personal care home, there may be only an administrator, a few direct care staff persons and the residents. Large personal care homes may have directors, supervisors, specialists, housekeeping and nutrition staff as well as three shifts of direct care staff persons.

At the center of the care TEAM is the resident and his/her needs and preferences. A TEAM, when it works together well, can provide better and more comprehensive care to a resident than staff members working separately. Think of a TEAM, any kind of TEAM. It could be a group to which you belong, a sports TEAM on which your child plays or one you see on TV. What makes that TEAM work well? Maybe they win, have good sportsmanship, do something to help others or simply complete what they set out to accomplish. Effective TEAMS have the following traits:

  • Work toward a common goal.
  • Talk to each other.
  • Support one another.
  • Share responsibility.
  • Strive to improve.

Common goal:

Working on a TEAM means having a common goal that is shared by everyone. What is the goal of the personal care home TEAM?

Communication (or talking) is the glue that keeps the TEAM on track toward its goal. Your communication with the resident is important to learning about the kind of life he/she wants and how you can best assist the resident to achieve that lifestyle. To your supervisor, you communicate changes you see or learn from the resident. With co-workers you share ideas on better ways to do a task, or get/lend a helping hand. Knowing that you’re not alone can make your job much more satisfying.

Supporting TEAM members:

Each TEAM member has different strengths. Becoming an effective TEAM requires that we recognize our own strengths and know when to ask for support or guidance. You can start by asking yourself, “What did I do on the job today that I thought was good? What would I have done differently? What would help me do better?” By honestly answering these questions, you will learn what strengths you can offer the TEAM and when to go to TEAM members for ideas or help. By observing and calling upon our TEAM members’ strengths, we learn how to share the work so that each person feels supported and valued.

Your role on the care TEAM:

As a direct care staff person, you play a key role on the care TEAM because you provide the day-to-day care for residents. You may see more than anyone else about what is going on with an individual. You are responsible for contacting your supervisor or others on the care TEAM as directed to get the help any resident needs. You will provide important information to the rest of the care TEAM through your daily observations, reporting and documentation. You can help maintain your awareness of a resident’s care needs by following these steps:

  1. Watch for changes. Notice changes that may signal the need for special attention or additional care.
  2. Regularly review with your supervisor, and with staff on the previous shift, any written documentation (such as resident’s charts, progress notes and medication record) for updates on a resident’s needs.
  3. Report and document all changes. Report changes in a resident’s needs.

Initial and annual assessment:

An initial assessment is done with a new resident 15 days after he/she moves to the home. This assessment gives a snapshot of the resident’s preferences and needs for assistance. The resident, family members, physicians and current caregivers are all asked to share information as part of the assessment so that the home can develop a good support plan.

The resident is asked about his/her need for assistance with ADLs and IADLs, communication, medication administration and mobility. The resident’s mental health and memory are assessed. The need for health and social services are noted. The resident’s choices, preferences for activities, religious practice, likes and dislikes are listed. This assessment is done each year or more often if the needs of a resident change.

Support plans:

Each personal care home has support plans that show the special needs and services for each resident including medical, dental, vision, hearing and mental health services. It explains the resident’s ability to take their medications and how staff should assist. The plan will explain if the resident needs help to walk, bathe or dress and the type of help he/she needs. The plan will also explain the social activities and other services that are specially designed for each resident. The support plan must be accessible by direct care staff persons at all times.

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