Care Plans and Legal Issues in Admission and Transfer

From Clicklaw Wikibooks

Prospective residents often only have 48 hours in which to decide to accept the admission to the particular facility and to move there. At the time of the new resident’s admission, the Operator may have only limited or out of date information on the new resident. The Residential Assessment Instrument carried out in the community and used to assess needs may have taken place recently, several months or even years ago.

As good standard practice, the Operator is expected to review the resident’s pre-admission and admission documents; the physician's assessment and orders, and other pertinent health assessments. The Operator is also expected to conduct and document an initial assessment of the resident within 24 hours of admission which identifies immediate care needs (e.g. diet and medication); risk factors (e.g. allergies, dysphagia, falls, behaviour); personal preferences; and a contact person.(1)

The Operator must develop and complete an individualized care plan for each resident within thirty days of his or her admission to a care facility. “Care plan” means an individualized plan for the provision of services and support to a person in care that takes into consideration the person’s abilities and physical, social and emotional needs as well as their cultural and spiritual preferences. As part of the development of a comprehensive care plan, issues related to end of life planning and advance directives may be discussed with a resident and his or her family or support persons, and documented. (2) Legal issues related to care plans and case conferences are discussed in the next chapter (Chapter Four “Legal Issues When Living in Residential Care”) and Chapter Six “Capacity & Consent”.


  1. Model Standard, 3. Standard: 3. Residents' individual health needs and psychosocial status are assessed by the interdisciplinary team.
  2. RCR, s. 81. Note the Vancouver Coastal Health Director of Licensing. “Advance Directives” document states six weeks.
This information applies to British Columbia, Canada. Last reviewed for legal accuracy by BC Centre for Elder Advocacy and Support, June 2014.

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