Together, with resident input, a Multidisciplinary Team will develop a plan of care. Each discipline is represented on the team, and members include the clinical coordinator, social worker, food service manager, activity coordinator and a representative from Rehabilitation Services, if appropriate.
The Multidisciplinary Team meeting is scheduled to review each resident’s plan of care with the resident and a responsible party, within a few days of admission. Residents and the responsible party are notified in writing of this meeting.
Upon admission the team will work with a resident to develop a safe and orderly discharge.
The goals created by the resident, their responsible party, and the Multidisciplinary Team will serve as the guideline for determining when the discharge will take place.