Professional Guardianship Standards:
Series One Standards of Care Planning and Documentation
By Pamela D. Wilson, CSA, MS, BS/BA, CG
Almost anyone can be a professional guardian. Are the results the same from guardian to guardian or is there a difference between professional guardians who commit to implement the standards of membership organizations? How might wards benefit from guardians whose actions support a higher standard of care and oversight? Here are a few other questions to ponder:
- Is there a difference in the level of oversight and quality of care received by a ward depending on the commitment, education, and expertise of the guardian?
- Do some guardians fail to implement standards of care planning and documentation because it’s too much trouble (who would really know) or does this occur because conservators or trustees question the benefit?
- Is there value in membership in a national organization like the National Guardianship Association with established standards of care?
The mission of the National Guardianship Association is to advance the nationally recognized standards of excellence in guardianship. NGA set the standard for quality in guardianship by establishing national practice standards for individuals. (www.guardianship.org)
If you are regularly involved with the role of guardianship through your position in a law practice, social or adult protective services, a county office, or a care team partner are you aware of the NGA standards? If so, are the professional guardians with whom you work following standards for care planning and documentation?
How would you know? Are you familiar with the concept of care planning? Do you value and understand the benefit of ongoing and historical documentation to serve as a record of communication with physicians and other providers to ensure that actions taken on behalf of a ward are not harmful, but beneficial? Are you aware of the importance of ongoing contact with care partners to ensure that care plans are being implemented?
When care “goes bad” it is often the historical record that provides insight into actions that should be taken to resolve a care concern. Documentation is also helpful in the event of a court hearing where testimony must be provided and recollection of events that were not documented may be rusty at best.
This article is the first in a series to offer education to build a greater understanding of the high level of responsibility of an individual accepting the role of a professional guardian. Guardian is more than a title—for anyone accepting this role there should be a commitment to a higher standard of care and service and to ongoing education that supports aspects related to the ward’s health, well-being, physical, social, and vocational needs.
Care planning to support the initial plan and ongoing care and documentation of contacts, care team meetings, and review of documentation is undervalued by those not responsible for the life or death aspect of a ward. For those outside of the guardianship role this activity may be viewed as an inefficient or ineffective use of time. Care planning sets the stage for goals and the identification of care partners and services and supports for the ward. Care planning also involves monitoring, determining measures of success, and compiling results.
According to NGA Standard 13: Guardian of the Person: Initial and Ongoing Responsibilities, Sections 2, 3, and 4 guardians must develop a written care plan for each ward that includes: personal information, preferences, medical information, care team partners, assessments of medical, psychological and social functioning and all other information related to the care and well-being of the ward.
Two important components of Section 3 are:
- Documentation of all client and collateral contacts, including the date, time, and activity
- Progress notes that are as detailed as necessary to reflect contacts made and work done regarding the person
Section 4 requires:
- Ongoing assessments and substantive communication with service providers
- Participation in care planning conferences and the development of plans
- Examination of all services and charts, notes, log evaluations, and other documents to ascertain that the care plan is being followed
Looking at these two sections, these standards might seem like a great deal of effort and time devoted to “paperwork,” versus activity. Alice in Wonderland posed the question: how do you get there when you don’t know or don’t care where there is?
The “there” related to guardianship is the development and monitoring of the care plan to deliver positive results for the ward. Without a plan and ongoing action it is difficult to effectively support the care of a ward especially when there are multiple care providers involved who may not have an accurate recall of events.
Care planning supports regular and ongoing communication with the care team that may be comprised of care community staff, individual caregivers, physicians, physical or occupational therapists and others. This type of care team and the communication between care team partners is critical so that goals are met and care plans are implemented.
Why document contact with care providers? That’s easy—unless you have a photographic memory, information, details, and commitments are easily forgotten. Some care providers commit to perform certain aspects of care and fail to follow through resulting in harm to a client. Others take a particular course of action without seeking approval from the guardian and a client is harmed. Written memos, emails, and verbal communication are methods to ensure that requests are received and carried out in the manner agreed. Guardians with experience repeat the common mantra, “if it’s not documented it didn’t happen.” Documentation saves lives and protects the ward.
Documentation is important for many reasons. Here are just a few:
- Information to provide a historical record for a ward related to all aspects of care that may be shared with a care team who questions why or why not a certain activity is or is not approved.
- Avoiding medical errors, for example by documenting past treatments or allergic reactions to certain medications so that physicians may be educated and avoid incorrect diagnosis or prescriptions. Yes it happens!
- Monitoring of improvements, progress, and forward movement.
- A comparison of health related aspects, for example blood pressure, weight gain or loss or extremity swelling that indicates a concern for action. Daily caregivers become immune to these numbers – they are important.
- Monitoring the actions of care community providers or family members who view the person as difficult due to behaviors and who unintentionally participate in neglect or abuse through verbal responses or physical actions. How many times have you heard a caregiver become verbally impatient with a resident? How many times have you heard an exhausted family member lose a temper?
- Documentation of support and ongoing communication to avoid a community asking the resident to leave if ongoing challenges exist. If a community feels supported the likelihood of a rushed discharge is minimized.
- Documentation from visit to visit to identify comparisons and information that a care partner should have relayed but did not. Surprises occur when visits occur by way of “oh we didn’t want to bother you, BUT.”
There are times when guardians act in the role of an advocate by informing communities that care is not meeting standards, that a caregiver is not a good match, that a client is not being cared for appropriately. Drop in visits to communities often show surprising findings. By comparing visit to visit, areas of concern are more easily identified and patterns may occur. One of the best ways to find out the day to day pattern of a client or any changes in condition or care is to develop relationships with care staff who may honestly provide the inside story of what happens in a community.
Guardians (professional and family) should have a historical reference of care and know the ward’s condition and care needs better than anyone else.
A story that I commonly tell is one of a ward who was in a skilled nursing community and had a significant change in condition. The nursing staff wanted to place the ward on hospice because of hallucinations regarding seeing and talking to a dead spouse and the belief that the ward was actively dying. My years of experience with this ward, including documentation of past changes in condition, indicated that this change in condition was due to pneumonia and a urinary tract infection.
The staff disagreed with me for about an hour and refused to send the ward to the emergency room. Finally after great debate the ward was sent to the emergency room and was found—not to be actively dying—but diagnosed with pneumonia and a urinary tract infection. If I had not disagreed with the staff, the ward would have likely died due to the severity of the infection. A family member in the role of guardian may not have felt comfortable disagreeing with the care staff and unfortunately their family member would have died.
Is there a difference in the level of oversight and ultimately the level of care received by the ward depending on the commitment and education of the individual acting as a guardian?
There is a significant difference. Most family caregivers who become guardians have little or no expertise in the areas of caregiving, healthcare, or community care. It’s likely that this new role of guardian was thrust on a family member unexpectedly. Family guardians serve to the best of their ability with good intentions and available skills versus the expertise of a professional certified guardian who is expected to be well versed in all aspects of caregiving, healthcare and community care.
Guardians who voluntarily become members of a professional organization like the National Guardianship Association are more likely to support higher standards of care. These individuals also participate in ongoing education to improve skills and knowledge. For these individuals, the role of guardian is a profession, not a “side job” or a hobby added on to a full-time career in a different area.
Some professional guardians have the breadth of experience so as not to accept information at face value—even if the information or an opinion is provided by another professional.
Another story – I received a call from a CNA at a care home that my ward needed a wheelchair. Interesting was that I visited this person the prior day and there was no need for a wheelchair; the ward was doing well and was engaged in activity. After asking a sequence of questions I learned that the ward had become weak early in the morning and was suffering from exhaustion and gastrointestinal issues. These conditions resulted in the CNA believing that the ward needed a wheelchair to support mobility versus the ward needing medical care.
I have many similar stories where intervention was beneficial to the ward and examples where family members may not have made the same observation or decision. Without documentation, medical tests may be repeated unnecessarily, medication changes may occur that result in adverse care situations, and the little things that repeat time after time may not be noticed for example, a fall precluding the diagnosis of a urinary tract infection.
Knowing what questions to ask is critical in acting as the squeaky wheel for a ward. There are no stupid questions. Documentation is supportive in this area to look at trends or changes that may allow identification of a new treatment plan. Questioning whether a physician has the right expertise to treat a specific ailment is the role of a guardian. Not all physicians are equal; specialists offer value much like the specialization that guardians acquire after years in the profession.
Physicians also benefit from information specific to changes in condition or behaviors. While isolated incidents may be of concern, physicians find it helpful if a paper trail or log is implemented and maintained relative to specific conditions. For example input and output logs that may indicate an individual is frequently dehydrated or sleep logs that indicate very few hours of sleep. The more specific information provided to a physician the better the outcome. Many wards are unable to describe the conditions or concerns experienced.
Expertise by way of years of experience and involvement with a large number of wards (or clients) does make a difference in the care provided and the ultimate outcome that is sometimes life or death. Ongoing oversight, care planning, documentation of visits, review of chart information and logs, and communication with care partners is critical to supporting positive responses to complicated health issues.
Professional guardians have a duty to gain expertise that benefits the ward related to all aspects of care planning: hospitalizations or acute situations, medical care, mental health or behavioral care, physical abilities including activities and instrumental activities of daily living, care communities, care agencies, social, vocational, and recreational pursuits. Due to expertise, professional guardians, are able accomplish results for wards in a more efficient and effective manor including advocating for beneficial services and medical care. Where family members may be intimidated by physicians or other healthcare providers, professional guardians have the duty of advocacy.
Is a care plan really necessary – doesn’t everyone receive the same level of care?
By developing care plans specific to each care team partner the outcome for the ward is much better than having a generic plan. For example it may be important for an individual to bathe each morning where another prefers to bathe in the evening. Another person may take medications easily while another may require medications to be ground and placed in applesauce or pudding. Some wards are slow in actions; it may take one person an entire hour to finish a meal while another person rushes through the meal and is finished in 10 minutes. Should the slow person be penalized by having their plate of food removed versus allowing the person to sit at the table as long as needed to complete a meal? What about a resident who likes to sleep in late and is deemed a behavioral problem because staff attempts to do a wake-up call at 6 a.m.? At the time I am retired I certainly will not be waking up at 6 a.m.
While these may seem like petty issues, when we find ourselves in a similar situation years down the road, we can only hope that there is someone paying attention to the small details, preferences, and trends of our life to ensure that we receive better than average care.
Do professional guardians fail to implement standards because it’s too much trouble—it’s possible?
Standards exist with membership in most professional organizations. It is the responsibility of the professional guardian to embrace and implement standards of the organization of which one is a member.
It is also the responsibility of the guardian to educate the conservator or the trustee about the value of the care plan to the ward. Funds are to be spent for the benefit of the ward. Funds are to be spent to support quality of life. I have worked with many conservators or trustees who lack understanding of the progression of a disease and supports that are beneficial for quality of life; they admit that they are the “money” expert not a healthcare expert.
Some conservators or trustees seek information to support appropriate financial decisions related to care. There are situations where I may engage the expertise of a medical or psychological expert to make or confirm a recommendation so that the conservator or trustee is more comfortable that the recommendation is reasonable, prudent, and beneficial.
Those not working in the world of fiduciary responsibility may be unfamiliar with organizational standards and may be quick to criticize the actions of a guardian who makes the extra effort to adhere to standards when other guardians do not adhere to the standards. I frequently hear from care staff, “the other guardians we work with are not as particular or interested as you relative to the care of the ward.” This makes me feel good knowing that this care staff understands that I work toward a higher standard of care. These comments also make it easier for me to elaborate my expectations relative to the care of the ward.
Educating the community involved in guardianship (and conservatorship) is important. It’s easy to understand why we do what we do and more difficult to understand the role and responsibilities of another individual—unless we ask and seek to understand. We’re all busy working on projects and running from place to place, making it easy to miss significant areas of care or neglect occurring within the care system.
Is there value in membership in national organizations with established standards of care?
The National Guardianship Association was founded in in 1988. In 1997 the organization established the Center for Guardianship Certification to support individuals with an interest in participating in professional standards and ethics. Value exists in the education and access to peers working in similar positions throughout the United States.
It is the responsibility of guardians to educate those with whom they work including attorneys, social and adult protective services, county office personnel and care team partners who may fail to understand that the fiduciary responsibility to support and advocate for care includes ongoing care planning and documentation. The responsibility of a guardian is to advocate and to ensure that the ward receives the best care possible that results in a positive quality of life. In many cases the guardian cannot fulfill this endeavor alone; many times it takes a team of care partners working together to fulfill the expectations and requirements of a care plan that also requires documentation of progress and review of documentation of care.
Many of our wards have no one but the guardian. If guardians fail to implement high standards the guardian fails the ward.
Pamela D. Wilson, MS, BS/BA, CG, CSA, Certified Senior Advisor specializes in working with family and professional caregivers to navigate healthcare and aging concerns. Wilson, an expert in the field of caregiving, has personally helped thousands of family and professional caregivers since 2000 in her career as an advocate, a care navigator, and an educator. Through her company, The Care Navigator, she is an advocate and service provider in the roles of guardian, power of attorney, care manager, and transition specialist.
She was producer and host of The Caring Generation®, from 2009 to 2011, an educational radio program for caregivers on 630 KHOW-AM. Her new book, The Caregiving Trap: Solutions for Life’s Unexpected Changes, is available through all major bookstores as well as on PamelaDWilson.com. You can follow Pamela on YouTube, Facebook, Twitter, and Linked In.