Care Planning: The Road Map for Individualized Resident Care

Care Planning: The Road Map for Individualized Resident Care Kathy Sanders RN, RAC-CT, DNS-CT Sanders Consulting kathy@mdshelp.com 1 Disclaimer The Care Planning: Care Planning: The Road Map for Individualized Resident Care was developed as an educational program and reference for long-term care staff. To the best of our knowledge, it reflects current federal regulations and practices. However, it cannot be considered absolute and universal. The information contained in this workshop must be considered in light of the individual organization and state regulations. The authors disclaim responsibility for any adverse effect resulting directly or indirectly from the use of the workshop material, from any undetected errors, and from the user s misunderstanding of the material. 2 Disclaimer Continued The authors put forth every effort to ensure that the content, including any policies, recommendations, and sample documents used in this training, were in agreement with current federal regulations, recommendations, and practices at the time of publication. The information provided in this training is subject to revision based on future updates and clarifications by CMS. 3 1

Objectives The learner will be able to: Describe the relationship between the RAI process, the care plan, and quality resident care Discuss the relationship between the MDS, CAT s, CAA s and the care plan Discus the role of critical thinking in the care planning process List the components of an effective care plan Define interim care plan Give an example of an I Format care plan 4 Introduction The care planning requirements reflect the facility s responsibilities to provide necessary care planning that results in care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for the resident. 5 Introduction Care planning fosters quality resident care by: Facilitating communication among the Interdisciplinary Team (IDT) members Providing staff with consistent information about the resident's problems, strengths, and needs Instructing staff on how to meet the individual resident s needs Allowing updates and revisions according to the resident's changing needs Including the resident s voice and choice 6 2

RAI Process Design Assessment (MDS 3.0) Decision Making (CAAs) Care Plan Development Care Plan Implementation Evaluation 7 Care Plan Development The care plan must aim to address the following: Prevent avoidable decline Manage risk factors Address resident strengths Evaluate treatment objectives and care outcomes Respect the resident s right to refuse treatment Offer alternative treatments Use an interdisciplinary approach Involve the resident, family, or other resident representative Involve direct care staff in the process Use current standards of practice CMS s RAI Version 3.0 Manual, Chapter 4 8 Resident Assessment Instrument (RAI) Process The RAI Process consists of three basic components: The Minimum Data Set (MDS) Version 3.0 The Care Area Assessment (CAA) Process The RAI Utilization Guidelines 9 3

Links in the(rai) Process The critical link between the MDS 3.0 and care planning results from two key areas: Care Area Assessments Care Area Triggers 10 What are the CATs? Care Area Triggers or CATs are the triggering mechanisms of the MDS 3.0 They are specific response options that serve as indicators of the twenty care areas that affect nursing home residents. When information entered into the MDS 3.0 triggers a response, additional assessment and care area review is required. 11 What are the CAA s? The Care Area Assessment (CAA) Process is guided by professional standards of practice and regulatory requirements. It is designed to guide the IDT through the comprehensive assessment of a resident s functional status. 12 4

CAAs There are 20 CAAs Delirium Visual Function Activity of Daily Living (ADL) Functional/Rehabilitation Potential Urinary Incontinence and Indwelling catheter Psychosocial Well-Being Behavioral Symptoms Falls Feeding Tubes Dental Care Psychotropic Medication Use Cognitive Loss/Dementia Communication Pain Return to Community Referral Mood Sate Activities Nutritional Status Dehydration/Fluid Maintenance Pressure Ulcer Physical Restraints 13 Using the CAAs CAAs are required for the following comprehensive clinical assessments Admission Assessments Annual Assessments Significant Change in Status Assessments Significant Correction of Prior Full Assessments CAAs may also be used at any time, not just when an assessment is due, to provide in-depth review of a care area condition to assist with development of a care plan 14 Critical Thinking The Bridge from Assessment to Care Planning Collecting assessment data in itself is not sufficient to develop an effective plan of care Understanding the relevance of the data to the specific resident s situation is essential 15 5

Critical Thinking The Bridge from Assessment to Car Planning Definition of Critical Thinking: The intellectual process of reasoning, of logically analyzing all available data Purpose of Critical Thinking: To explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusions about it that integrates all available information and can, therefore, be convincingly justified (Kurfiss, 1988) 16 Critical Thinking Critical thinking includes: Integrating all available information and eliminating irrelevant information Using reasoning processes Exploring a situation to arrive at a hypothesis Logically analyzing data Arriving at reasonable conclusions about the resident s status, needs, problems, and strengths in order to create an effective plan of care 17 Critical Thinking The care plan is driven not only by identified resident issues and/or conditions but also by a resident s unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. MDS 3.0 Manual pages 4-9, 10 18 6

Critical Thinking A well developed and executed assessment and care plan: Looks at each resident as a whole human being with unique characteristics and strengths; Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident s functional status (MDS); Gives the IDT a common understanding of the resident; Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 19 Critical Thinking Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow-up; Reflects the resident/resident representative input and goals for health care; Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident s highest practicable level of wellbeing (care planning); Re-evaluates the resident s status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. MDS 3.0 Manual pages 4-10 20 Critical Thinking Following the decision to address a triggered condition on the care plan, key staff or the IDT should subsequently: Review and revise the current care plan, as needed; and Communicate with the resident or his/her family or representative regarding the resident, care plans, and their wishes. MDS 3.0 Manual pages 4-10 21 7

Critical Thinking The overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation). 2. Managing risk factors to the extent possible or indicating the limits of such interventions. 3. Addressing ways to try to preserve and build upon resident strengths. 4. Applying current standards of practice in the care planning process. 22 Critical Thinking 5. Evaluating treatment of measurable objectives, timetables and outcomes of care. 6. Respecting the resident s right to decline treatment. 7. Offering alternative treatments, as applicable. 8. Using an appropriate interdisciplinary approach to care plan development to improve the resident s functional abilities. 9. Involving resident, resident s family and other resident representatives as appropriate. 10. Assessing and planning for care to meet the resident s medical, nursing, mental and psychosocial needs. 23 Critical Thinking 11. Involving the direct care staff with the care planning process relating to the resident s expected outcomes. 12. Addressing additional care planning areas that are relevant to meeting the resident s needs in the long-term care setting. MDS 3.0 Manual pages 4-10 If you read through Chapter 4 of the RAI 3.0 Manual, the word individual is repeated over and over Not just with the Care Planning, but also with the CAAs. 24 8

Care Plan Development The process of the RAI assessments is the foundation of care planning in long-term care The full RAI Process is designed to result in a plan of care that guides ALL levels of the resident s care givers. 25 Care Plan Development The Holistic View: The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or CAAs [42CFR483.20(b)] 26 The Holistic View The RAI Version 3.0 guides the nursing home team to view residents as individuals who consider both quality of care and quality of life as significant and necessary. The RAI components promote a resident-valued emphasis. The interdisciplinary approach influences the resident s experience of care by impacting work practices of the team. A holistic focus helps the IDT generate individualized, person-centered/directed plans of care that guide day-to-day care for residents 27 9

Care Plan Development CMS has defined six general care planning areas it considers useful for nursing homes: Functional Status Rehabilitation/Restorative Nursing Health Maintenance Discharge Potential Medications Daily Care needs 28 Care Plan Development Functional Status Functional status limitations are identified using the MDS and CATs All conditions requiring intervention must appear on the care plan once reviewed in the CAAs process The conditions identified by the RAI should be clearly linked to problems addressed on the car plan. 29 Care Plan Development Rehabilitation/Restorative Nursing Assess and care plan potential for all types of rehab needs Assess and care plan for risks and complications Be alert to the need for referrals 30 10

Care Plan Development Health Maintenance Monitoring of disease processes that currently are being treated Include stable and unstable conditions that need monitoring If the resident is taking medications for conditions, regular monitoring of edema, vital signs, blood glucose, etc., should be care planned Terminal care Special treatments such as dialysis or ventilator support 31 Care Plan Development Discharge Potential Assess at admission, annually, and PRN In some cases assessment for discharge potential may need to be completed with each MDS Focus on what needs to be done in order for the resident to be safely and successfully discharged 32 Care Plan Development: Medications Care Plan should include: Intent for the use of the medication Non-Pharmacological approaches Goals or expected outcome for the resident How to monitor the resident s progress relative to those goals What actions to take when the progress is not as expected 33 11

Care Plan Development: Medications Care Plan should include: Potential adverse consequences that appear in FDA Black-Box Warning Resident may be particularly susceptible to May be rare May have sudden onset May be irreversible Impact physical function Impact psychosocial status Other possible effects Action to take if adverse consequences occur 34 Care Plan Development: Medications Sedatives / Hypnotics Include other interventions, such as sleep & hygiene programs, implemented before and while using these drugs Methods for monitoring for adverse consequences Gradual dose reductions Timing and method What to look for in terms of possible adverse consequences associated with tapering of the particular medication 35 Care Plan Development Daily Care Needs Daily care needs that are specific to the resident and are out of the ordinary must be addressed on the care plan Nursing home staff must use their professional judgment when making these decision It is imperative to talk to direct care staff on all shifts to determine the individual resident care needs for that shift. 36 12

Care Plan Development In developing the holistic care plan, utilize all available assessment data. In addition to the RAI Assessments, other assessments may include: Admission Nursing Assessment Hydration, I&O, Fall Risk Assessment, Risk for skin breakdown, Restorative Assessment and other nursing assessments Hospital H&P All ancillary department assessments: SS, Activities, Dietary, etc. Lab & X-ray reports Discussion with resident and family 37 Care Plan Development: Interdisciplinary Team Approach The care plan must be prepared by an interdisciplinary team that includes the attending physician, an R.N. with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident s needs, and, to the extent practicable, the participation of the resident, the resident s family or the resident s legal representative. [42CFR483.20(k)(2)] 38 Care Plan Development: Interdisciplinary Team Approach Professional disciplines, as appropriate to the resident, must work together to provide the greatest benefit to the resident. The mechanics of how the IDDT meets its responsibility to develop an interdisciplinary care plan are at the discretion of the facility. Face-to-face care plans meetings are not required. The physician must participate, and may arrange for alternative methods of providing input, such as one-on-one discussions and conference calls. 39 13

Care Plan Development: Interdisciplinary Team Approach Resident and family participation The nursing home must assist residents to participate The nursing home must provide enough time to information exchange and decision making The nursing home must make an effort to schedule care plan meetings at a convenient time of the day for residents and their families. The resident has the right to refuse specific treatments and to select among treatment options before the care plan is implemented. 40 Care Plan Development: Interdisciplinary Team Approach While federal regulations affirm the resident s right to participate in car planning and to refuse treatment, the regulations do not create the right for a resident, legal surrogate or representative to demand that the facility use specific medical intervention or treatment that the facility deems inappropriate. Statutory requirements hold the facility ultimately accountable for the resident s care and safety, including clinical decisions. [42CFR483.20(k)(2)] 41 Care Plan Components Although federal regulations do not prescribe a specific care plan format, regulations do mandate the components to be included in a care plan: Problem List / Problem statements specific to the individual Measurable objectives Measurable timetables Interventions to attain or maintain the resident s highest practicable physical, mental, and psychosocial well-being Interventions that would be required but are not provided due to resident s refusal of treatment Date of the entry, signature of the IDT member, discipline responsible for implementation 42 14

Care Plan Components The Problem Statement: Formulated based on critical analysis of the IDT assessments, including triggered CAAs Defines the issues specific to the resident s problem to facilitate effective goal setting and development of appropriate interventions Is NOT a restatement of the medical diagnosis, but usually defines problems arising from the medical problem. 43 Care Plan Components The Problem Statement: Disease-related problem statement: Medical Diagnosis combined with signs/symptoms exhibited by the resident Difficulty with dressing in the morning RT Osteoarthritis AEB complains of discomfort while putting arms in his sleeves and buttoning the buttons. Occasionally strikes out at staff during cares RT dementia AEB requires slow approach after simple explanation of procedures. Becomes SOB with ambulation RT COPD AEB ambulates in 15 foot increments before resting. 44 Care Plan Components The Problem Statement: Nursing Diagnosis problem statement: In practice, usually combined with etiology to create descriptive nursing diagnosis statement Confusion, acute Violence, directed at others Physical mobility, impaired. 45 15

Care Plan Components The Problem Statement: Nursing Diagnosis problem statement: Example Acute confusion RT severe pain and effects of pain medication AEB inability to find room independently Violence directed at others RT Organic Brain Syndrome AEB slapping direct care staff while they are giving care Impaired physical mobility RT SOB related to CHF AEB unable to walk more than 15 feet without tiring, becoming SOB. 46 Care Plan Components The Problem Statement: The functional problem statement shows how: The condition is a problem for the resident, NOT how it creates a problem for the staff; The condition limits or jeopardizes the resident s ability to complete tasks of daily living; or The problem affects the resident s well-being in some way Mr. Smith cannot find his room independently Mrs. Jones slaps the face of direct care staff while they are giving personal care Mrs. Brown is unable to walk more than 15 feet because of shortness of breath 47 Care Plan Components The Problem Statement: MDS Related Problem Statements Problem statements should reflect terminology of the MDS Etiology & signs/symptoms (s/s) may be added: Memory/recall ability deficit RT severe pain & effects of pain medication AEB inability to find own room. Physically abusive behavioral symptoms RT dementia AEB slapping direct care staff while they give care. Shortness of breath with impaired physical mobility RT COPD AEB inability to walk more than 15 feet. 48 16

Care Plan Components The Problem Statement: The functional problem statement sample for Social Services: Cognition; Mood; Psych-Well Being; Activities; Psych Drug Mr. Smith misses doing things with his wife like they used to related to RT CVA, Hemiplegia, Aphasia, as exhibited by AEB loves to play cards and is willing to learn new card games. He becomes suspicious and paranoid of his wife at times as to her faithfulness to him. He has a Dx. Of depression and is on scheduled Citalopram. 49 Care Plan Components The Problem Statement: Regardless of the working or format, the problem statement must contain enough information to ensure that interventions selected are related to the true problem Example: For a resident who fell, the problem statements below would result in different interventions: Fall climbing out of bed unassisted Slipped on urine walking to bathroom. 50 Care Plan Components: The Goal Goal: Reasonable expected outcome of care based on the content of the specified problem which provides precise objections for the resident to meet: Action-oriented Goal for the resident, not for staff Measurable Time-limited Individualized for each resident 51 17

Care Plan Components: The Goal According to the RAI User's manual, the goal statement should include: a subject, a verb, modifiers, and a time frame. Subject Verb Modifiers Time Frame Mr. Jones Will walk Up and down five stairs with the help of one CNA using a gait belt Daily for the next 30 days 52 Care Plan Components: The Goal Additional Example: Mr. Smith will walk 50 feet with a front wheeled walked, gait belt, and limited assist of 1 person daily for the next 30 days Subject: Mr. Smith Action Verb: will walk Modifiers: 50 ft. with front-wheeled walker, limited assist of 1, gait belt, Time Frame: daily for the next 30 days. 53 Care Plan Components: The Goal From Previous Examples: Mr. Smith will find his room independently with verbal cues within 2 weeks. Mrs. Jones will have <2 episodes per day of slapping direct care staff while they are giving care by July 22, 2015. Mrs. Brown will walk 25 feet with supervision of 1 person without s/s of SOB by August 25, 2015. 54 18

Care Plan Components: The Goal Reasonableness of the goal For Mrs. Jones, no episodes of slapping with 24 hours might NOT be a reasonable goal Realistic time frame: Federal regulations required quarterly reassessment at a minimum. Resident-specific assessment data should dictate how often reassessment should be done Mr. Smith might need 2 weeks of med changes, behavior modification, etc., to reach independence. 55 Care Plan Components: The Goal Each problem must have a least one goal A problem may have more than one goal If Mrs. Brown is unable to walk more than 15 feet RT SOB and hip pain, a second goal would address the hip pain. Related problems may share the same goals and approaches. 56 Care Plan Components: The Goal Example of combined SS goal getting back to Mr. Smith: 2 goals from 1 combined problem A. Mr. Smith will participate in an card game with his wife weekly by 7/28/2015 B. Mr. Smith will have no adverse drug reactions (ADR s) from the Citalopram by 7/28/2015. 57 19

Care Plan Components: Interventions Interventions are: Instructions to the IDT Developed by correlating assessment data with goals of care Specific to the individual s problems, needs, strengths, and risks Interdisciplinary, with assigned accountability Consistent with the established plan of care Based on professional standards of quality 58 Care Plan Components: Interventions Vary in focus depending on desired outcome Facilitate improvement in status Prevent avoidable decline in status Provide palliative care Categories of interventions to consider include: Assessments Observations and monitoring Specific clinical approaches designed to achieve specific outcomes Resident and family teaching activities 59 Care Plan Components: Interventions Interventions are instructions to the IDT which should include concise, focused action statements of direction regarding the resident s care: Action verb: Ambulate Amount, distance, quantity, such as 15 Feet Method of to be utilized, such as with front-wheeled walker Frequency, when appropriate, such as TID. Additional clarifying information or direction, such as, with gait belt and limited assist of 1 person. 60 20

Care Plan Communication The Care Plan is the tool for providing continuity of care: All care givers must be informed about the details of the plan initially and with any changes Goals and interventions must be communicated to all care givers consistently to ensure that everyone is working with the same outcomes in mind Resident and family must be included, and the final care plan must be discussed with the resident or the representative. 61 Care Plan Communication An effective system for consistently communicating care planning decision to everyone who needs it is essential to positive resident outcomes. It cannot be overstated how important it is to include direct care staff in the process. 62 Care Plan Time Frames Federal regulations link timing with assessments Within 7 days of completion of the initial Admission Assessment Quarterly With Significant change in status Exception: The nursing home is responsible for addressing resident s needs from the moment of admission by developing an interim care plan. [483.20(b)] 63 21

Care Plan Time Frames: The Interim Care Plan Initiation of Care Planning process upon admission: Utilize hospital discharge/transfer orders, SNF admission orders, initial nursing assessment. Should also include enough information about ADL status for staff to safely care of the resident Include routine care instructions to maintain or improve functional abilities until comprehensive assessment is complete. Conduct an initial CAA review for identified problem or potential problem, such as restraint, incontinence, dehydration, falls, or psychotropic drug use 64 Care Plan Time Frames: Significant Change in Status Care plan must accurately represent the care to be delivered at any given point in time. Should be re-evaluated & revised on an on-going basis to reflect changes in the resident and care the resident is receiving (RAI user s Manual, p. 2-40) Services provided or arranged must be in accordance with each resident s written plan of care. 65 Care Planning and Culture Change Culture Change is about transforming nursing homes for both residents and staff. It creates home within the nursing home through designation of neighborhoods, rather than units, with consistent assignments and resident-directed care. Care planning is a practice being influenced by Culture Change. Two newer types of care plan formats are: I Format Care Plan Full Narrative Format Care Plan 66 22

I Format Care Plan I Format Care Plans are the most popular of the new formats. They are: Written in the voice of the residents, actually using the individual s own statements Written so that care givers can hear the resident speaking when they read the care plan Used for cognitively impaired residents by interviewing family or surrogates to learn the wishes and life preferences of the resident Able to mesh with both the RAI s MDS 3.0 CAAs and the Quality Indicator Survey (QIS) interview processes. 67 I Format Care Plan Problem / Need Goal Approaches I am at risk for skin breakdown due to my incontinence I want to remain free of any skin problems 1. Keep me clean and dry 2. I prefer to turn every hour while I am awake 3. Do not wake me at night to turn me. 4. I do not want to wear briefs, but I will wear a smaller pad in my underwear 5. I take Ditropan for bladder spasms to cut down on leaking. 68 Full Narrative Care Plan Full Narrative Care Plans are written in paragraphs with resident-specific information that is easy to read. When read from start to finish, a full narrative care plan is similar to reading a story about the resident. 69 23

Full Narrative Care Plan All About Me My Social History: My name is Julianne Wellington, and I prefer to be called Julia. I was born on a farm near Lewiston, NE on December 8, 1930. My parents were immigrants from Scotland. My childhood was simple and fun, and although life was tougher then, it didn t seem like it. I graduated from college and became a teacher at a country one-room school house southeast of Lewiston. I married Peter Wellington in 1948 and we had 4 children, all who live nearby. Holidays and birthdays are important to my family, and I want to participate in them. 70 Full Narrative Care Plan Communication / Memory Goal: I want to keep my mind stimulated to maintain my memory, I like eye contact, so please look at me when you speak to me. I like discussing current events, so feel free to ask me my opinion. 71 Full Narrative Care Plan Mental Wellness Goal: I want to feel like I am important and needed. I have always been very involved in my surroundings and would like to keep it that way. I sometimes get discouraged and may feel like keeping to myself. Don t take this as a problem unless it lasts more than a week or so. Don t schedule appointments or baths for me during these time.s 72 24

Full Narrative Care Plan Personal Care ADLs Goal: I want to do as much as I can for myself Hearing: My hearing is good 73 CAA and Care Planning Clarifications From the MDS 3.0 Manual 1. Care planning is a process that has several steps that may occur at the same time or in sequence. The following key steps and considerations may help the IDT develop the care plan after completing the comprehensive assessment: a. Care Plan goals should be measurable. b. The IDT may agree on intermediate goal(s) that will lead to outcome objectives. 74 CAA and Care Planning Clarifications From the MDS 3.0 Manual 2. Intermediate goal(s) and objectives must be pertinent to the resident s condition and situation (i.e., not just automatically applied without regard for their individual relevance), measurable, and have a time frame for completion or evaluation. 3. Care plan goal statements should include: The subject (first or third person), the verb, the modifiers, the time frame, and the goal(s). 75 25

CAA and Care Planning Clarifications From the MDS 3.0 Manual 4. A separate care plan is not necessarily required for each area that triggers a CAA. a. Since a single trigger can have multiple causes and contributing factors and multiple items can have a common cause or related risk factors, it is acceptable and may sometimes be more appropriate to address multiple issues within a single care plan segment or to cross reference related interventions from several care plan segments. b. For example, if impaired ADL function, mood state, falls and altered nutritional status are all determined to be caused by an infection and medication-related adverse consequences, it may be appropriate to have a single care plan that addresses these issues in relation to the common causes. 76 CAA and Care Planning Clarifications From the MDS 3.0 Manual 5. The RN coordinator is required to sign and date the Care Area Assessment (CAA) Summary after all triggered CAAs have been reviewed to certify completion of the comprehensive assessment (CAAs Completion Date, V0200B2). a. Facilities have 7 days after completing the RAI assessment to develop or revise the resident s care plan. b. Facilities should use the date at V0200B2 to determine the date at V0200C2 by which the care plan must be completed (V0200B2 + 7 days). 6. The 7-day requirement for completion or modification of the care plan applies to the Admission, SCSA, SCPA, and/or Annual RAI assessments. 77 CAA and Care Planning Clarifications From the MDS 3.0 Manual a. A new care plan does not need to be developed after each SCSA, SCPA, or Annual reassessment. b. Instead, the nursing home may revise an existing care plan using the results of the latest comprehensive assessment. c. Facilities should also evaluate the appropriateness of the care plan at all times including after Quarterly assessments, modifying as needed. 7. If the RAI (MDS and CAAs) is not completed until the last possible date (the end of calendar day 14 of the stay), many of the appropriate care area issues, risk factors, or conditions may have already been identified, causes may have been considered, and a preliminary care plan and related interventions may have been initiated. A complete care plan is required no later than 7 days after the RAI is completed. 78 26

CAA and Care Planning Clarifications From the MDS 3.0 Manual 8. Review of the CAAs after completing the MDS may raise questions about the need to modify or continue services. Conditions that originally triggered the CAA may no longer be present because they resolved, or consideration of alternative causes may be necessary because the initial approach to an issue, risk, or condition did not work or was not fully implemented. 9. On the Annual assessment, if a resident triggers the same CAA(s) that triggered on the last comprehensive assessment, the CAA should be reviewed again. a. Even if the CAA is triggered for the same reason (no difference in MDS responses), there may be a new or changed related event identified during CAA review that might call for a revision to the resident s plan of care. 79 CAA and Care Planning Clarifications From the MDS 3.0 Manual b. The IDT with the input of the resident, family or resident s representative determines when a problem or potential problem needs to be addressed in the care plan. 10. The RN Coordinator for the CAA process (V0200B1) does not need to be the same RN as the RN Assessment Coordinator who verifies completion of the MDS assessment (Z0500). The date entered in V0200B2 on the CAA Summary is the date on which the RN Coordinator for the CAA process verified completion of the CAAs, which includes assessment of each triggered care area and completion of the location and date of the CAA assessment documentation section. See Chapter 2 for detailed instructions on the RAI completion schedule. 80 CAA and Care Planning Clarifications From the MDS 3.0 Manual 11. The Signature of Person Completing Care Plan Decision (V0200C1) can be that of any person(s) who facilitates the care plan decision making. a. It is an interdisciplinary process. b. The date entered in V0200C2 is the day the RN certifies that the CAAs have been completed and the day V0200C1 is signed. MDS 3.0 Manual Page 4-11, 12 81 27

THANK YOU Questions? 82 Information Sources Where to get more information MDS 3.0 Manual V1.15, 10/01/2017, Chapter 4 AANAC: AANAC.org State Operations Manual, Appendix P-PP, Survey Guidance to Surveyors 83 REFERENCES References: MDS 3.0 Manual V1.13, 10/01/2015 MDS Intensive Course Notes by Carol Maher RN, RAC-CT, AANAC MT, RAI Manual Contributor. 84 28

THANK YOU Kathy Sanders RN, RAC-CT, DNS-CT Sanders Consulting 630 N. 3 rd St. Tecumseh, NE 68450 Wk: (402) 335-2736 Cell: (402) 921-0250 kathy@mdshelp.com 85 29