COMPREHENSIVE RESIDENT CENTERED CARE PLAN P ERSON-CENTERED CARE P LANS Baseline Care Plan F 279 Integration with Resident Assessment Instrument (RAI) and Care area Assessment (CAA) process PASRR Discharge Planning and Discharge Summary Process (New) WENDY BOREN, BS, RN, REGION 2 CAROL SIEM, MSN, RN, BC, GNP, RAC-CT REGION 7 QIPMO Clinical Consultants/Quality Educators Sinclair School of Nursing F TAG 279 BASELINE CARE PLAN BASELINE CARE PLAN The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident s admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders and medications (D) Therapy services. (E) Social services. (F) PASRR recommendation, if applicable. The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan (i) Is developed within 48 hours of the resident s admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). Carol Question: If you do the Comprehensive Care Plan within the first 2 days how are you going to incorporate the MDS sections into the care plan BASELINE CARE PLAN BASELINE CARE PLAN The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident s medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv)any updated information based on the details of the comprehensive care plan, as necessary. Where do we start? Check with your software to see if they have developed an app that can be used to pull out a base line care plan using physician orders as the basis This is not an exclusive MDS coordinator proposition. Base line care plans will be done on weekends and holidays depending the admission date Review your admission process to incorporate such things as the discharge plan and initial goals Don t assume you know the answers See Sample Baseline Care Plan in your handouts 1
F 279 483.21(B) COMPREHENSIVE CARE PLANS F 279 483.21(B) COMPREHENSIVE CARE PLANS (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2)and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and (ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR recommendations. If a facility disagrees with the findings of the PASRR, it must indicate its rationale in the resident s medical record. F 279 483.21(B) COMPREHENSIVE CARE PLANS SURVEYOR PROBES (iv) In consultation with the resident and the resident s representative (s) (A) The resident s goals for admission and desired outcomes. (B) The resident s preference and potential for future discharge. Facilities must document whether the resident s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. Examples: This is Carol s forever home, or Carol plans to be discharged to her Daughter Michelle s home Does the care plan address the needs, strengths and preferences identified in the comprehensive resident assessment? Is the care plan oriented toward preventing avoidable declines in functioning or functional levels? How does the care plan attempt to manage risk factors? Does the care plan build on resident strengths? Does the care plan reflect standards of current professional practice? Do treatment objectives have measurable outcomes? Corroborate information regarding the resident s goals and wishes for treatment in the plan of care by interviewing residents, especially those identified as refusing treatment. Determine whether the facility has provided adequate information to the resident so that the resident was able to make an informed choice regarding treatment. If the resident has refused treatment, does the care plan reflect the facility s efforts to find alternative means to address the problem? For implementation of care plan, see 483.20 F 280. F280 483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iv) The right to receive the services and/or items included in the plan of care. (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. F 280 483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must- (i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident s strengths and needs. (iii) Incorporate the resident s personal and cultural preferences in developing goals of care. 2
F 280 483.21(B) COMPREHENSIVE CARE P L ANS PROBES 483.21(b) Comprehensive Care Plans (2) A comprehensive care plan must be (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Was interdisciplinary expertise utilized to develop a plan to improve the resident s functional abilities? For example, did an occupational therapist design needed adaptive equipment or a speech therapist provide techniques to improve swallowing ability? Do the dietitian and speech therapist determine, for example, the optimum textures and consistency for the resident s food that provide both a nutritionally adequate diet and effectively use oropharyngeal capabilities of the resident? Is there evidence of physician involvement in development of the care plan (e.g., presence at care plan meetings, conversations with team members concerning the care plan, conference calls)? PROBES F281 In what ways do staff involve residents and families, surrogates, and/or representatives in care planning? Do staff make an effort to schedule care plan meetings at the best time of the day for residents and their families? Ask the ombudsman if he/she has been involved in a care planning meeting as a resident advocate. If yes, ask how the process worked. Do facility staff attempt to make the process understandable to the resident/family? Ask residents whether they have brought questions or concerns about their care to the attention of facility s staff. If so, what happened as a result? (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must (i) Meet professional standards of quality. Intent The intent of this regulation is to assure that services being provided meet professional standards of quality (in accordance with the definition provided below) and are provided by appropriate qualified persons (e.g., licensed, certified). Interpretive Guidelines Professional standards of quality means services that are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include: Current manuals F282 F282 483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must (ii) Be provided by qualified persons in accordance with each resident's written plan of care. (iii) Be culturally-competent and trauma informed. [ 483.21(b)(iii) will be implemented beginning November 28, 2019 (Phase 3)] Probes Can direct care-giving staff describe the care, services, and expected outcomes of the care they provide; have a general knowledge of the care and services being provided by other therapists; have an understanding of the expected outcomes of this care, and understand the relationship of these expected outcomes to the care they provide? 3
GUIDANCE for DISCHARGE D I S C H A R G E P L A N N I N G REQUIREMENTS The comprehensive care plan must address a resident s preference for future discharge, as early as upon admission, to ensure that each resident is given every opportunity to attain his/her highest quality of life. This encourages facilities to operate in a person-centered fashion that addresses resident choice and preferences. DISCHARGE PLANNING (IN CARE PLANS) 483.21(c) Facilities must develop and implement an effective discharge planning process. Identify discharge goals and needs Develop a discharge plan, including referrals to local agencies, etc. for returning to the community. DISCHARGE PLANNING (IN CARE PLANS) Information provided to receiving provider (another home, resident s home, etc): Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; Special instructions and/or precautions for ongoing care, as appropriate, which must include, if applicable, but are not limited to: o Treatments and devices (oxygen, implants, IVs, tubes/catheters); o Precautions such as isolation or contact; o Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; DISCHARGE PLANNING (IN CARE PLANS), CONT D DISCHARGE PL ANNING (IN CARE PL ANS) The resident s comprehensive care plan goals; and All information necessary to meet the resident s needs, which includes, but may not be limited to: Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received); and Most recent relevant labs, other diagnostic tests, and recent immunizations. require regular re-evaluation of residents to identify changes that require modification of the discharge plan and update the care plan to reflect these changes. MAKE SURE YOU DATE AND INITIAL ANY CHANGES. And, they want the MDS (or care plan coordinator) involved in the discharge planning process. 4
F TAG 283 F TAG 284 (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident s representative. (iii) Reconciliation of all pre-discharge medications with the resident s post-discharge medications (both prescribed and over-the-counter). (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. F TAG 284 F TAG 284 ( CONT) The facility s discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability & the resident s or caregiver s/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident s goals of care and treatment preferences. 483.21(C)(2) DISCHARGE SUMMARY PROBES When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The postdischarge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident s follow up care and any postdischarge medical and non-medical services. Does the discharge summary have information pertinent to continuing care for the resident? Is there evidence of a discharge assessment that identifies the resident s needs and is used to develop the discharge plan? Is there evidence of discharge planning in the records of discharged residents who had an anticipated discharge or those residents to be discharged shortly (e.g., in the next 7-14 days)? Do discharge plans address necessary post-discharge care? Has the facility aided the resident and his/her family in locating and coordinating post-discharge services? What types of pre-discharge preparation and education has the facility provided the resident and his/her family? Does the discharge summary have information identifying if the resident triggered the CAA for return to community referral? 5
Comprehensive Care Plan F656 483.21(b) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights. This includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. INTENT & DEFINITIONS Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident s medical, physical, mental and psychosocial needs. Resident s Goal : The resident s desired outcomes and preferences for admission, which guide decision making during care planning. Interventions : Actions, treatments, procedures, or activities designed to meet an objective. Measurable : The ability to be evaluated or quantified. Objective : A statement describing the results to be achieved to meet the resident s goals. Person-centered care : means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives 5 PART PERSON-CENTERED CARE PL ANNING Resident Rights Care Plan Writing and Inclusion Discharge Care Plan Requirements Care Plan Meetings What Surveyors Want to Know R E S I D E N T R I G H TS 483.10 RESIDENT RIGHTS 483.10 RESIDENT RIGHTS Right to request care plan conferences Right to request revisions to care plan Right to be informed in advance of changes in care plan Right to sign after significant changes in care plan Right to have personal and cultural preferences addressed in care plan. Resident has right to be informed of total health status Right to request, refuse, or discontinue treatment Right to participate in care planning including the right to identify individuals or roles to be included in the care planning. Guardians, lawyers, friends, priests whomever the resident requests. Right to participate in family groups and have family members participate as well. 6
483.10 RESIDENT RIGHTS 483.10 RESIDENT RIGHTS A resident may not be able to identify a specific person they want included in the planning process, but that should not prevent the resident from including a role, such as someone to provide spiritual, nutritional or behavioral health input. Right to choose his/her attending physician. If physician chosen refuses or does not meet LTC regulations, facility may seek alternate. Facility must discuss alternate physician issue with resident. 483.10 RESIDENT RIGHTS Right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with interests, assessments, and plan of care. Right to make choices about aspects of life in facility that are significant to resident. C A RE P L A N W RITING A N D I N CLUSION COMPREHENSIVE CARE PL ANS, BY CMS All services furnished to attain, maintain highest practicable well being Any services required but not provided due to resident s exercise of rights Any specialized services (PASSAR) or specialized rehab Resident goal for admission and desired outcome Resident preference for discharge Discharge plans COMPREHENSIVE CARE PL ANS, BY CMS The resident and/or representative MUST participate in the interdisciplinary team that develops the resident s care plan. All physician orders MUST be documented in a care plan. Facilities are required to provide written advance directive information to the resident and representative. 7
COMPREHENSIVE CARE PLANS COMPREHENSIVE CARE PL ANS, BY CMS All physician orders MUST be documented in a care plan What is your facility policy on What is a care plan for your facility Sample Suggestion: Lakeview Nursing home considers the following to be parts of the comprehensive care plan: Physician orders, MARs, TARs, Care Plan, Care Cards, Pocket guides, Closet information, etc Reviewed and revised after each assessment Meet professional standards of quality Be provided by qualified persons Be culturally competent and trauma informed COMPREHENSIVE CARE PL ANS, BY CMS F550 ( FORMERLY F242) Resident has the right to see the care plan along with the right to sign it after significant changes. Encourage the facility to provide a copy of the comprehensive care plan upon request. Residents have right to review and obtain copy of their medical record, the care plan is a part of their medical record. F550 The resident has the right to (3) Make choices about aspects of his or her life in the facility that are significant to the resident. the facility must create an environment that is respectful of the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. This includes actively seeking information from the resident regarding significant interests and preferences in order to provide necessary assistance to help residents fulfill their choices over aspects of their lives in the facility. Sample Care Plan Meeting Summary Residents shall not have their personal lives regulated or controlled beyond reasonable adherence to meal schedules and other written policies which may be necessary for the orderly management of the facility and the personal safety of the residents. 19 CSR 30-88.010 (41) F550 (formerly 242) Source: Missouri State Code of Regulations, https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-88.pdf Resident s Name Date Reason for meeting: (circle one) Quarterly Annual Significant Change Nursing notes Dietary notes: Weight from previous quarter Current weight Dietary changes: (circle one) Y/N Date of change Reason for change Resident s preferences Social services notes: Therapy notes: (circle one) PT/OT/ST/Restorative Resident/Family requests/complaints: Signatures of attendance Date Resident/family requests a copy of careplan Y/N 8
CARE PLAN WRITING AND INCLUSION Person-centered, individual care plans are the key!! Cultural preference Spiritual preferences Dietary preferences (see New Dining Standards at Pioneer Network Coalition for evidence-based practices) Sleep/natural wakening routine practices Activity preferences Clinical practices (pain management) GET RID of the General Practices get specific and to the root cause Traditional Example: Problem: Resident has a hx of falling d/t weakness and unsteady gate. Goal: Resident will remain free from falls for the next 90 days (don t we wish!) INSTEAD Jim has a history of falling late in the afternoon. He walks all throughout the day with his walker. Jim has early stages of dementia and gets restless. Walking helps him relieve anxiety; however, by the end of the day he is tired. Staff will be available to walk with Jim and engage him, particularly as he tires, using the poetry gait rhythm method that encourages rest stops. Jim s goal will be to reduce the number of episodes and risk of injury from falling, while improving his quality of life through meaningful engagement. Assessment CARE PLAN WRITING AND INCLUSION Try interviewing over coffee instead a clipboard why do think social services knows more than nurses do?! What was your normal routine? Break it down morning, noon, night Relationships who helps calm them down?? Pleasures (church groups, clubs, veteran s networks, etc.) CMS says we have to provide opportunities to continue these social networks. Preferences on medication administration, lighting, noise REMEMBER this is their home and we all have things we re picky about! WHAT IF THEY CAN T TELL YOU WHAT THEY WANT? Discuss with families what they think the person s goals would be now. If residents are unable and family is unavailable, then staff can step in and determine as best as they can from really knowing the person, what the person s goals might be. REMINDER on the MDS, if they can t tell you, then we should know that from section B. Lots of times these don t match. Talk to your CNAs and floor nurses!! They know this person s routine and what works and what doesn t better than you do!! MOM ALWAYS CARE PLAN WRITING AND INCLUSION Category Bathing Requirement/ Goal To maintain personal hygiene Preferences Lydia prefers to bath in the mornings from the sink. She has never bathed in the shower and is uncomfortable doing so. Inclusion Lydia is able to wash her arms and legs but asks for assistance with other areas. She asks that staff apply her lavender lotion after bathing. Staff will assist Lydia with sponge baths and will support her ability to do as much as possible for herself. Typical Care Plan Problem Goal Intervention 9
CARE PLAN WRITING AND INCLUSION CARE PLAN WRITING AND INCLUSION Category Requirements Preferences Inclusion Narrative I Care Plan Dental Care Susan will maintain healthy teeth and gums. Susan prefers to brush her teeth before breakfast and after supper. She likes mint toothpaste and she has a difficult time flossing on her own because of the arthritis in her fingers. Staff will assist Susan with her dental care by following her routine and preparing her toothbrush if needed. Staff will assist her with flossing after supper at her discretion, and will offer professional dental services bi-annually or as needed. COMMUNICATION/MEMORY: I have a little bit of trouble with my memory. I have been diagnosed with early Alzheimer s dementia. I am aware of my situation, my caregivers and my family. Occasionally I am a little forgetful and confused. Be sure to orient me as part of our conversation while you are providing care. Remind me what is going to happen next. Introduce yourself every time you meet me until I am able to remember you. If I should be more confused than you normally see me, or I don t remember details about my day, notify the nurse. Often times this means that I am having health complications, which my nurse will be able to assess. I enjoy conversation about your family and your children. I have had a lot of experience raising kids. If you would like some advice on beauty, I love to share my opinion. Especially on how you should do your hair or what clothes look good on you. Being a model all those years has paid off. GOAL: I want to remain oriented to my family and my caregivers. I want to be able to remember special events and holidays with your reminders. CARE PLAN WRITING AND INCLUSION Possible person-centered categories for a care plan Dental Care Bladder Management Skin Care Nutrition Fluid Maintenance Pain Management and Comfort Activities Discharge Plan CARE PLAN WRITING AND INCLUSION Possible person-centered categories for a care plan Social History Memory Enhancement & Communication Mental Wellness Mobility Enhancement Safety Visual function It s not about leaving out the medical. Instead, it s about managing, educating, and living a normal life with that condition. GUIDANCE for Refusal of Care GUIDANCE for PASRR In situations where a resident s choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident s health or safety, the comprehensive care plan must identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility s attempts to find alternative means to address the identified risk/need should be documented in the care plan. Additionally, a resident s decision-making ability may decline over time. The facility must determine how the resident s decisions may increase risks to health and safety, evaluate the resident s decision making capacity, and involve the interdisciplinary team and the resident s representative, if applicable, in the care planning process. In addition to addressing preferences and needs assessed by the MDS, the comprehensive care plan must coordinate with and address any specialized services or specialized rehabilitation services the facility will provide or arrange as a result of PASRR recommendations. If the IDT disagrees with the findings of the PASRR, it must indicate its rationale in the resident s medical record. The rationale should include an explanation of why the resident s current assessed needs are inconsistent with the PASRR recommendations and how the resident would benefit from alternative interventions. The facility should also document the resident s preference for a different approach to achieve goals or refusal of recommended services. Residents preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan. REMEMBER the RULES Residents retain the right for basic living choices and considerations See guidelines at 483.10(c)(6) (F578) (Request/Refuse/Discontinue Treatment;Formulate Adv Directives ) for additional guidance concerning the resident s decision to refuse treatment. 10
PASRR PASRR Any client that is admitted to a Medicaid certified bed must complete and submit a DA-124 application (Regardless of the client's payment source; example private pay or insurance) Behavioral is defined as an individual s social or metal activities This includes dually certified beds (both Medicare and Medicaid) Applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or others must be transferred immediately to an appropriate facility PASRR PASRR Points will be assessed for the amount of assistance required, the complexity of the care and the professional level of assistance necessary, based on the level of care critiera For individuals seeking admission to a long term care facility the level has changed from 21 points to 24 points as approved by the Governor. If a Medicaid certified bed is requested and the clinet has a diagnosis of a serous mental illness or mental retardation/developmental disability, the state of Missouri mandates DA-124 A/B and C application be submitted to COMRU LEVEL II SCREENING LEVEL II SCREENING Completed by Bock Associates for MI and MR/DD screenings completes the Level II Screening. DMH has nine working days to complete the Level II screening excluding weekends and holidays DMH makes the contact with the Bock Association Who needs it? Everyone who enters a Medicaid certified bed and meets at least one of the following criteria: Has had inpatient psychiatric treatment in the past 2 years Was suicidal or homicidal even if Dementia is the primary psych diangsis Has a diagnosis of Mental retardation (diagnosed before age 18) Has a Developmental Disability (DD) condition related to Mental retardation (Onset before age 22) Examples: TBI, Cerebral Palsy, seizure disorder, etc 11
GUIDANCE for CARE AREA ASSESSMENT (CAA) If a Care Area Assessment (CAA) is triggered, the facility must further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility s rationale for deciding whether or not to proceed with care planning for each area triggered must be recorded in the medical record. There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment, but may not cause a CAA to trigger. The facility is responsible for addressing these areas and must document the assessment of these risks, weaknesses or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team (IDT), in conjunction with the resident and/or resident s representative, if applicable,, must develop and implement the comprehensive care plan and describe how the facility will address the resident s goals, preferences, strengths, weaknesses, and needs. C A RE P L A N M E ETINGS CARE PLAN MEETINGS 483.21(B) Must-have participants CNA who provides care Dietary staff No members of the IDT are required to participate in person. Facilities have the flexibility to determine how to hold IDT meetings whether in person or by conference call. The facility may determine that participation by the nursing assistant or any member, may be best met through email participation or written notes. We believe that this added flexibility will help to alleviate concerns of shortage and availability. And think PERSON-CENTERED! CARE PLAN MEETINGS 483.21(B) 483.21(b)(2)(ii)(F), to provide that to the extent practicable, the IDT must include the participation of the resident and the resident representatives. An explanation must be included in a resident's medical record if the IDT decides not to include the resident and/or their resident representative in the development of the resident's care plan or if a resident or their representative chooses not to participate. Remember it doesn t have to be in a large group or by the MDS coordinator conveying the information, asking for feedback, getting their opinion STILL counts! CARE PLAN MEETINGS CARE PLAN MEETINGS CMS encourages facilities to explore ways to allow residents, families and representatives to access care plan on a routine basis using technology solutions that enable real time access for authorized users. Face-time, Skype BEWARE of HIPPA violations! No careplan meetings in Wal-Mart 12
PERSON-CENTERED CARE PLAN MEETINGS 1.Ask yourself: Are you having a conversation about someone s care in their home or are you coming to a meeting because you have to, holding a clipboard, and checking off a list? 2.Are the various disciplines rattling off their speels then walking out of the room? 3.What is the ratio of staff to resident and family? Remind you of a firing squad? Think about who REALLY needs to be present. 4.Is it too cold, too hot, distracting, private, comfortable for the resident and family? W H AT S U RVEYORS WA N T TO K N O W Surveyor Questions Does the care plan address the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline? Are objectives and interventions person-centered, measurable, and do they include time frames to achieve the desired outcomes? Is there evidence of resident and, if applicable resident representative participation (or attempts made by the facility to encourage participation) in developing person-centered, measurable objectives and interventions? Does the care plan describe specialized services and interventions to address PASRR recommendations, as appropriate? Surveyor Questions Is there a process in place to ensure direct care staff are aware of and educated about the care plan interventions? Determine whether the facility has provided adequate information to the resident and, if applicable resident representative so that he/she was able to make informed choices regarding treatment and services. Evaluate whether the care plan reflects the facility s efforts to find alternative means to address care of the resident if he or she has refused treatment. Is there evidence that the care plan interventions were implemented consistently across all shifts? Impact in other areas If the surveyor identifies concerns about the resident s care plan being individualized and person-centered, the surveyor should also review requirements at: Resident assessment, 483.20 Activities, 483.24(c) Nursing services, 483.35 Food and nutrition services, 483.60 Facility assessment, 483.70(e) DEFICIENCY CATEGORIZATION Examples of Level 4, immediate jeopardy to resident health and safety, A resident has a known history of inappropriate sexual behaviors and aggression, but the comprehensive care plan did not address the resident s inappropriate sexual behaviors or aggression which placed the resident and other residents in the facility at risk for serious physical and/or psychosocial injury, harm, impairment, or death. The facility failed to implement care plan interventions to monitor a resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death. 13
DEFICIENCY CATEGORIZATION Continued DEFICIENCY CATEGORIZATION Continued Examples of Level 3, actual harm that is not immediate jeopardy The CAA Summary for a resident indicates the need for a care plan to be developed to address nutritional risks in a resident who had poor nutritional intake. A care plan was not developed, or the care plan interventions did not address the problems/risks identified. The lack of interventions caused the resident to experience weight loss. Lack of care plan interventions to address a resident s anxiety, depression, and hallucinations resulted in psychosocial harm to the resident Examples of Level 2, no actual harm, with potential for than more than minimal harm, that is not immediate jeopardy During the comprehensive assessment, a resident indicated a desire to participate in particular activities, but the comprehensive care plan did not address the resident s preferences for activities, which resulted in the resident complaining of being bored, and sometimes feeling sad about not participating in activities he/she expressed interest in attending. An inaccurate or incomplete care plan resulted in facility staff providing one staff to assist the resident, when the resident required the assistance of two staff, which had the potential to cause more than minimal harm. DEFICIENCY CATEGORIZATION Continued An example of Level 1, no actual harm with potential for no more than a minor negative impact on the resident For one or more care plans, the staff did not include a measurable objective, which resulted in no more than a minor negative impact on the involved residents. P H A S E 3 C A R E T H AT A D D R E S S E S U N I Q U E N E E D S O F H O L O C A U S T S U R V I V O R S, WA R S U R V I V O R S, D I S A S T E R S, A N D O T H E R P R O F O U N D T R A U M A A R E I M P O R TA N T A S P E C T O F P E R S O N C E N T E R E D C A R E. M O R E I N F O R M AT I O N T O C O M E 2 0 1 9 CMS Manual System Transmittal Pub. 100-07 State Operations Provider Certification-169-Advanced copy. Pages 205-210 RESOURCES Carmen Bowman, Edu-catering, Individualized Care Planning Centers for Medicare & Medicaid Services, 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489, [CMS-3260-F], Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, https://federalregister.gov/d/2016-23503 Missouri State Code of Regulations, https://www.sos.mo.gov/cmsimages/adrules/csr/current/19csr/19c30-88.pdf PASRR http://health.mo.gov/seniors/nursinghomes/pasrr.php 14