Client Care Plans & Assessments

Overview

Client care plans and assessments are the clinical and operational foundation of service delivery at TheKey. Assessments establish a client's needs, safety risks, and care goals at intake and at key transition points; care plans translate those findings into actionable instructions for caregivers. Together, they drive caregiver matching, billing eligibility, regulatory compliance, and client retention. Keeping care plans current — and reassessing proactively — is explicitly tied to quality outcomes, payor requirements (e.g., TransAmerica, WCB), and internal metrics such as the BCM pillars and Care Match C-P-E profiles.

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Key People

• Dr. Shadi — Clinical lead involved in framing how assessments and reassessments uncover client needs and translate into tailored benefits. [TheKey Home Care Essentials — 2025-02-06 — TheKey Operations]
• Ashley Mirone — Vice President of Business Development; partnered with Dr. Shadi on assessment-to-benefit strategy.
• Audra Williams — Recurring operational driver; issued BCM Tasks pilot reminders (2024-08) and responded to Care Match C-P-E profile update requirements.
• Megan Harris — Issued and enforced Care Match C-P-E profile update policy (2025-07, 2025-10); led Week 6 training on assessment as the foundation of care.
• Cheryl Cartwright / Matt Vijayan — Clarified in 2023 that Client Success Managers (CSMs) must attend assessments tied to care plan creation, not just initial intake conversations.
• Nancy Hopkins — Responsible for creating plans of care in ClearCare for specific clients (e.g., Irene Reitman). [Re: Missing Plan of Care — 2025-05-09]
• Amanda Ilines — Handles care plan input prior to Start of Care (SOC). [Care Plans — 2025-09-16]
• Chris Gerard — ATL market leader conducting weekly reassessments and care coordination touchpoints with HCLs and CSMs. [ATL Updates — 2025-08-14]
• Laurie Simpson — Escalated missing plan-of-care issues to operations staff.
• Tyler Ferguson — Issued communication expectations reminders tied to client needs routing. [2025-07-14]

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Processes & Policies

Initial Assessment

• Conducted in-person by a dedicated local Client Success Manager (CSM); walks through the client's daily routine, health needs, and preferences. [TheKey Sales Process Final]
• In Canada, the core clinical tool is the Living at Home Assessment (LHA), which must be completed within a defined scheduling window. [LHA_Business_Rules_Canada]
• National Intake Team referrals (e.g., via Caring.com and APFM) labeled "tentative initial assessment" are consultations only — not formal nursing assessments. [National Intake Team Tentative Assessments — 2023-02-28 — Audra Williams]
• During initial assessment, clients must be informed that supportive care workers cannot set up or administer medications. [TheKey Kansas Policies & Procedures Manual]
• Care plan must be inputted into the system prior to Start of Care (SOC). [Care Plans — 2025-09-16 — Amanda Ilines]

Care Plan Creation & Updates

• Care plan is created from assessment findings and must reflect realistic client goals — both what the client wants and what the client needs. [Quarterly Focus Webinar — 2017-05-02]
• Plans of care must be created in ClearCare (also referenced as WellSky); the Care Plan section includes ADLs and IADLs. [Re: Vidal — 2023-10-13]
• Care plans must be updated within 24 hours of a QA visit. [SLA_Existing_Client_Experience]
• When tasks are no longer relevant as client needs evolve, they should be removed to preserve accuracy of care notes. [Fun Fact Friday — 2026-03-06 — Bridgett Scherer]
• BCM (Balanced Care Method) pillars must be reflected and updated in care plans as part of ongoing reassessment. [BCM Tasks Pilot — 2024-08-09 — Audra Williams]

Reassessment

• Bi-annual in-person reassessment is required as a minimum standard, focusing on changes in home safety and independence levels in ADLs and IADLs. [SLA_Existing_Client_Experience]
• In-person reassessment is mandatory any time there is a noted change in condition, and must include a ClearCare Reassessment note and care plan update. [Updated_SLA_Client_Experience]
• Post-hospitalization: An in-person reassessment must be completed. [Updated_SLA_Client_Experience]
• GMs are expected to identify clients requiring reassessment monthly and schedule those visits at the start of each month. [General_Manager_Playbook]

Care Match C-P-E Profile Updates

A C-P-E (Client-Profile-Environment) profile update is required:

• For all new clients
• After any assessment
• Upon completion of a reassessment
• When there is a change in condition or care plan update

[Care Match C-P-E Profile Update — 2025-07-07 — Megan Harris]

CSM Role in Assessments

• CSMs must be present for assessments tied to care plan creation.
• CSMs are not required for initial consultations to understand basic client needs. [Re: Meeting Request — 2023-03-22 — Cheryl Cartwright / Matt Vijayan]

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Timeline & Key Events

| Date | Event |

|------|-------|

| 2015-09 | Initial assessment in Hudson used to build incident response documentation. |

| 2016-03 | Early guidance issued: not all assessment items apply at intake; some become relevant only at reassessment. |

| 2017-05 | Quarterly webinar stresses care plans must address both client wants and clinical needs. |

| 2018-03 | Cohort group notes RN conducting all assessments and writing initial care plans for new clients; transition to Care Manager model underway. |

| 2020-07 | Google Docs used for Assessment & Care Plan documents (Regine Mimran, Don Carver cases). |

| 2023-02 | Audra Williams clarifies national intake "tentative assessments" are not formal nursing assessments. |

| 2023-03 | Cheryl Cartwright and Matt Vijayan define CSM attendance policy for assessments. |

| 2024-08 | BCM Tasks Pilot launched in WellSky; reminder issued to reassess and update BCM pillars in care plans. |

| 2025-02 | Dr. Shadi and Ashley Mirone collaborate on using assessments to convert client needs into tailored service benefits. |

| 2025-05 | Missing plan of care for Irene Reitman escalated due to TransAmerica request; Nancy Hopkins directed to create in ClearCare urgently. |

| 2025-07 | Megan Harris issues C-P-E profile update requirements; Audra Williams confirms policy. |

| 2025-08 | ATL team (Chris Gerard) conducting weekly reassessment and care coordination touchpoints. |

| 2025-09 | Amanda Ilines confirms care plan input completed prior to SOC for new clients. |

| 2025-10 | Megan Harris flags missing C-P-E profiles; reissues training materials. |

| 2026-03 | Bridgett Scherer reminds team to remove irrelevant tasks from care plans as needs evolve. |

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Key Decisions

• CSMs attend care-plan-linked assessments, not routine intake consultations — a boundary clarified in March 2023 by Cartwright and Vijayan.
• In-person reassessment is non-negotiable for condition changes and post-hospitalization; virtual or phone reassessments do not satisfy this requirement.
• WellSky/ClearCare is the system of record for all care plans and reassessment notes; Google Docs (used pre-2021) has been superseded.
• Care plans must be live before SOC, not after — confirmed operationally in 2025.
• BCM pillars must be actively maintained in the care plan, not treated as one-time intake entries.

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Open Questions & Gaps

• ADL documentation gaps: At least one Montreal client (Vidal, 2023) had no ADLs recorded in ClearCare's assessment section, preventing completion of a disability tax credit form. Unclear whether this is a systemic gap or isolated case.
• LHA scheduling window: The LHA Business Rules document states the LHA must be completed within a defined timeframe, but the specific number of days is not captured in available excerpts.
• Reassessment frequency beyond bi-annual: The SLA specifies bi-annual in-person reassessment, but it is unclear whether specific client populations (e.g., high-acuity, post-hospital) have documented shorter cycles.
• RN vs. CSM assessment ownership: A 2018 cohort note describes an RN conducting all assessments and writing initial care plans. Current policy appears to assign this to CSMs — but the transition and any clinical oversight structure are not fully documented.
• National vs. local intake assessment handoff: The line between national intake "tentative assessments" and formal nursing assessments needs clearer documented protocol beyond Audra Williams' 2023 email.

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Related Topics

1. Care Match & C-P-E Profiles

2. WellSky / ClearCare System Usage

3. BCM (Balanced Care Method) Framework

4. Client Success Manager (CSM) Roles & Responsibilities

5. Start of Care (SOC) Onboarding Process