PATIENT CARE ASSESSMENT AND PLAN OF CARE TWYLA MOORE RN ARKANSAS DEPARTMENT OF HEALTH HEALTH FACILITY SERVICES Twyla.Moore@arkansas.gov 501-661-2201 This Session will Begin Momentarily. The Session is Being Recorded. Please mute your phone lines (*6). Following the Presentation, Lines will be Open for Q & A
OBJECTIVES TO UNDERSTAND WHO MAKE UP THE MEMBERS OF THE INTERDISCIPLINARY TEAM TO UNDERSTAND REGULATORY TIMEFRAMES FOR COMPLETION OF ASSESSMENTS AND PLAN OF CARE
INTERDISCIPLINARY TEAM The patient or designee Registered Nurse Physician treating the patient s ESRD Needs Social Worker Registered Dietitian
Assessment Criteria There are 14 care areas to be assessed. The interpretive guidelines assist in determining what should be included in the evaluation of the care areas. The regulatory tags are V502 to V515.
INITIAL ASSESSMENT The assessment is completed on all new patients within 30 days or 13 treatments beginning with the first dialysis session. Prior to the first dialysis treatment a Registered Nurse must complete an initial assessment. This is defined at V715. The facility s policy and procedure may have additional requirements to include in the first dialysis treatment assessment
Reassessment within 3 months A follow-up comprehensive must be done within 3 months after completion of the initial assessment.
ANNUAL REASSESSMENT FOR STABLE PATIENTS The first annual is due 12 months after the 3 month reassessment or 15 months after the patients admission to the facility. After the first annual, the comprehensive assessment would be due 12 months after the most recent comprehensive reassessment whether the assessment was routine or unstable.
UNSTABLE ASSESSMENT An unstable assessment is done monthly until the patient has been determined stable. The facility s policy and procedure for identifying the patient as unstable may be stricter than the regulatory requirement but at minimum must include the regulatory required definitions.
UNSTABLE ASSESSMENT The regulations identify the patient as unstable when: There is an extended or frequent hospitalization Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis
PLAN OF CARE The plan of care must be developed by the IDT and individualized according to the patient s assessed care needs, include measurable goals, expected outcomes and an estimated timetable to achieve the outcomes. The outcomes specified in the plan of care must be consistent with current evidence based professionally-accepted clinical practice standards. The plan of care tags are V540 tov562
INITIAL PLAN OF CARE Implementation must be completed by 30 calendar days after admission or 13 treatments beginning with the first treatment.
ANNUAL OR MONTHLY UPDATES TO THE PLAN OF CARE The plan of care must be performed within 15 days after the completion of the monthly or annual reassessment
PLAN OF CARE When the expected outcome (goal) is not achieved then the IDT must adjust the plan of care to reflect the patient s current condition, document in the record the reasons why the patient was unable to achieve the goals and implement plan of care changes to address the issue.
What is the MEASURES ASSESSMENT TOOL (MAT) Measures Assessment Tool (MAT) is a 2-page summary of the standards used in assessing compliance with regulatory requirements formatted in 5 columns to include the referenced V tag, the measure, the expected value(s), reference for the value(s), and where the surveyor should find the information during a survey. The current Version is 1.9.
HOW TO OBTAIN GUIDANCE Go to www.cms.gov/guidanceforlawsandregulations Then in the left hand column click on dialysis. On this page you will find: ESRD Program Interpretive Guidelines Manual (regulations) ESRD Surveyor Optional Worksheets ESRD Surveyor Laminates (includes MAT) ESRD Survey and Certification Letters ESRD Frequent Asked Questions
To Obtain CEU s The Survey Must be Completed! CEU s are only available for live session attendee s Your name will be populated on your certificate as entered in the Survey Once the survey is closed CEU s will no longer be available Certificates will be delivered via email in approximately 3 weeks You will be dropped off in the survey when you close out of the session. If you are attending in group setting email to receive a link to the Survey If you experience any problems contact Amber L. Harper, LCSW, NSW-C Patient Services Coordinator, ESRD Network 13 email: aharper@nw13.esrd.net Phone: 405-948-2255 DeeDee Velasquez-Peralta, LMSW Patient & Community Services Specialist, ESRD Network 12 email: DVelasquez-Peralta@nw12.esrd.net Phone: 816-880-1702