Dementia Care Plan Checklist for New Jersey Families

Why a Written Care Plan Is Not Optional

A dementia care plan serves two purposes that families rarely think about until it is too late. First, it organizes the daily chaos of caregiving into something manageable — medication schedules, behavioral triggers, safety protocols, and emergency contacts in one place. Second, and less obviously, it builds the clinical documentation trail that New Jersey's Medicaid system requires for MLTSS eligibility.

When the Office of Community Choice Options (OCCO) conducts a Pre-Admission Screening to determine whether your parent qualifies for long-term care services, the evaluator assesses cognitive function, behavioral challenges, and the level of assistance needed with activities of daily living. Families who walk into that screening with months of documented daily care logs have a dramatically stronger case than those relying on memory and verbal descriptions.

The Daily Care Log

A daily care log tracks the parent's functional abilities and behavioral episodes in real time. It does not need to be elaborate — consistency matters more than detail.

Record these items every day:

• ADL assistance provided: Did you help with bathing, dressing, toileting, transferring from bed to chair, or eating? Note what kind of help — verbal cueing only, hands-on assistance, or total dependence
• Medication management: Did you administer medications? Were any doses missed? Did the parent attempt to take the wrong medication or double-dose?
• Cognitive orientation: Did the parent know where they were? Could they recognize family members? Were they confused about the time of day?
• Behavioral incidents: Wandering attempts, agitation, aggression, sundowning episodes, refusal to eat or bathe, repetitive questioning
• Safety interventions: Did you prevent a fall, turn off a stove the parent left on, redirect the parent from leaving the house, or manage a driving-related concern?

Why this matters for MLTSS: The OCCO screening evaluates whether the parent needs assistance with three or more ADLs or has cognitive deficits requiring constant cueing and supervision. A daily log that shows the parent needs hands-on help with bathing, dressing, and toileting — documented over weeks, not described from memory — directly addresses the screening criteria.

The Clinical Documentation Folder

Beyond the daily log, maintain a folder with these documents:

• Physician's diagnosis — a formal letter documenting the type of dementia (Alzheimer's, Lewy body, vascular, frontotemporal) and the stage
• Neuropsychological evaluation results — if the parent has undergone formal cognitive testing, keep the full report
• Form PA-4 — the Physician Certification form that OCCO requires. Have the attending physician complete this before the PAS screening, not during
• Medication list — current prescriptions with dosages, frequencies, and the prescribing physician
• Hospital discharge summaries — any recent hospitalizations, emergency room visits, or urgent care encounters
• Behavioral assessment records — if a geriatric care manager or neurologist has conducted a behavioral assessment, include it

Building the Care Plan

A care plan is a living document. Start with these sections:

Safety protocols:

• Door and window alarm locations
• Stove safety measures (knob covers, auto-shutoff)
• Driving status and MVC notification (if applicable)
• Project Lifesaver enrollment status
• Emergency contact hierarchy

Daily routine:

• Wake and sleep schedule
• Meal times and dietary restrictions
• Medication schedule with administration notes
• Activity preferences (walks, music, gardening)
• Known sundowning window and management approach

Medical contacts:

• Primary care physician
• Neurologist or geriatrician
• Pharmacy
• Home health agency (if applicable)
• County ADRC and case manager

Legal status:

• Power of attorney — who holds it, where the document is stored
• Healthcare proxy — who is designated
• Advance directive — completed or not
• Guardianship status (if applicable)

When to Update the Plan

Dementia changes the rules constantly. Update the care plan when:

• The parent's ADL needs increase (needing hands-on help where verbal cueing used to be enough)
• A new behavioral symptom appears (wandering, aggression, hallucinations)
• A hospitalization or fall occurs
• The parent transitions between care settings
• A new provider joins the care team

Each update should be dated and kept. The historical record of declining function is exactly what an OCCO evaluator, an elder law attorney, or a Medicaid caseworker needs to see.

The New Jersey Dementia & Memory Care Guide includes printable daily care log templates, the PA-4 preparation checklist, and the complete OCCO documentation package designed to build the strongest possible clinical case for MLTSS approval.

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