Forms for the Protection of the Rights of NY Nursing Home Residents

Record-Keeping Form for NY Nursing Home Residents’ Concerns

Use this form to keep records of a problem or concern and how it is addressed by the facility. Keeping track of who you spoke to and when, what the response was, and what actions were taken to resolve the problem can strengthen your advocacy, both in the facility and beyond. This form can be used to facilitate conversations and follow-up with staff and administration, raise issues at resident or family council meetings, or support a complaint to a government agency.

NY Nursing Home Resident Assessment Planning Form

Nursing homes are required to conduct initially and periodically a comprehensive and accurate assessment of each resident’s functional capacity. Federal law requires that it identify and respond to a resident’s needs, strengths, goals, life history and preferences. This is very important because it forms the basis for a resident’s care plan, which outlines to services that the facility promises to provide.

Federal standards also require that the assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. The purpose of this form is to assist residents, families, and those working with them to prepare for and participate effectively in the assessment process. It can be used to identify areas of concern related to the required components of the assessment.

NY Nursing Home Resident Personal Preferences Form

Residents have preferences in respect to how they live their lives. Federal law requires that every resident’s preferences are recognized, respected, and reflected in the care and services they receive. While living with other people inevitably results in some compromises, the facility must take meaningful steps to meet each resident’s needs and preferences as an individual.

Residents and families are encouraged to use this form to document preferences which can be shared with staff to foster person-centered care.

THIS FORM IS TO PROVIDE INFORMATION ON PERSONAL PREFERENCES ONLY. IT IS NOT TO BE USED TO IDENTIFY A RESIDENT’S CLINICAL OR MEDICAL NEEDS, NOR DOES IT SUPPLANT PLANS OF CARE OR MEDICAL RECORDS.