6 (1) Every licensee of a long-term care home shall ensure that there is a written plan of care for each resident that sets out, (a) the planned care for the resident; (b) the goals the care is intended to achieve; (c) clear directions to staff and others who provide direct care to the resident; and (d) any other requirements provided for in the regulations. Based on assessment of resident (2) The licensee shall ensure that the care set out in the plan of care is based on an assessment of the resident and on the needs and preferences of that resident. Plan to cover all aspects of care (3) The licensee shall ensure that the plan of care covers all aspects of care, including medical, nursing, personal support, mental health, nutritional, dietary, recreational, social, palliative, restorative, religious and spiritual care. Integration of assessments, care (4) The licensee shall ensure that the staff and others involved in the different aspects of care of the resident collaborate with each other, (a) in the assessment of the resident so that their assessments are integrated and are consistent with and complement each other; and (b) in the development and implementation of the plan of care so that the different aspects of care are integrated and are consistent with and complement each other. Involvement of resident, etc. (5) The licensee shall ensure that the resident, the resident’s substitute decision-maker, if any, and any other persons designated by the resident or substitute decision-maker are given an opportunity to participate fully in the development and implementation of the resident’s plan of care. Development of initial plan of care (6) When a resident is admitted to a long-term care home, the licensee shall, within the times provided for in the regulations, ensure that the resident is assessed and an initial plan of care developed based on that assessment and on the assessment, reassessments and information provided by the placement co-ordinator under section 51. Duty of licensee to comply with plan (7) The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan. Staff and others to be kept aware (8) The licensee shall ensure that the staff and others who provide direct care to a resident are kept aware of the contents of the resident’s plan of care and have convenient and immediate access to it. Documentation (9) The licensee shall ensure that the following are documented: 1. The provision of the care set out in the plan of care. 2. The outcomes of the care set out in the plan of care. 3. The effectiveness of the plan of care. When reassessment, revision is required (10) The licensee shall ensure that the resident is reassessed and the plan of care reviewed and revised at least every six months and at any other time when, (a) a goal in the plan is met; (b) the resident’s care needs change or care set out in the plan is no longer necessary; or (c) care set out in the plan has not been effective. Reassessment, revision (11) When a resident is reassessed and the plan of care reviewed and revised, (a) subsections (4) and (5) apply, with necessary modifications, with respect to the reassessment and revision; and (b) if the plan of care is being revised because care set out in the plan has not been effective, the licensee shall ensure that different approaches are considered in the revision of the plan of care. Explanation of plan (12) The licensee shall ensure that the resident, the resident’s substitute decision-maker, if any, and any other persons designated by the resident or substitute decision-maker are given an explanation of the plan of care. Limitation on disclosure (13) Subsection (12) does not require the disclosure of information if access to a record of the information could be refused under the Personal Health Information Protection Act, 2004. Access to plan (14) Nothing in this section limits a right of access to a plan of care under the Personal Health Information Protection Act, 2004.