Deficient practices related to care planning continue to be a frequently cited issue for providers. Effective care planning can be challenging and requires an IDT approach to ensure effective systems that will lead to better resident outcomes, as well as survey readiness. Here are 5 things you should do now to improve care plan processes:

  1. Promote thorough and meaningful assessments

Remind direct care staff that assessments are more than rote tasks that need to be completed. Emphasize the importance of accurate assessments, direct communication with the resident or resident representative, and direct observation of the resident to adequately identify needs, strengths, goals, and preferences. The comprehensive care plan must be developed to meet a resident’s medical, nursing, and mental and psychosocial needs. Inevitably, these needs are identified through multidisciplinary assessments and evaluations beginning upon admission and conducted subsequently throughout the resident’s stay. The expectation is that this valuable, individualized information is then analyzed and included in the plan of care where appropriate. Care Area Assessments (CAAs) are also included in the care planning process to assist the IDT in determining if an issue or concern should proceed to care plan.

      • Record review – Is the care plan comprehensive? Is it consistent with the resident’s specific conditions, risks, needs, preferences, and behaviors?
  1. Set realistic goals and interventions

The resident and/or resident representative are members of the IDT. Include them in goal setting and discussions regarding approaches to their care. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident concerning daily routines and preferred activities, and having an understanding of the resident’s life before coming to reside in the nursing home. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, the resident’s goals for admission and desired outcomes, the resident’s preference and potential for future discharge, and discharge plans. Services provided or arranged must be culturally-competent and trauma-informed.

      • Record review – Does the care plan include goals for admission, measurable objectives, timetables, and desired outcomes?
  1. Disseminate the information

Successful implementation of approaches begins with communication, and there should be a process in place to ensure direct care staff are aware of and educated about care plan interventions. This continues to be imperative throughout the length of the resident’s stay as changes in condition, care, and services are likely to occur. Furthermore, the resident and/or representative should be kept informed and encouraged to participate in discussions surrounding the plan of care.

      • Record review – Is there evidence of resident or resident representative participation in developing resident-specific, measurable objectives, and interventions? If not, is there an explanation as to why the resident or representative did not participate? Is there a process in place to ensure direct care staff are aware of and educated about the care plan interventions?
  1. Validate approaches

Care plan interventions should be implemented consistently across all shifts. Direct observation should be periodically performed where appropriate (e.g., ADL assistance, fall prevention methods) to validate interventions. Resident or representative interviews may be necessary to validate other approaches to care including staff adherence to residents’ preferences and routines.  In situations where a resident’s choice to decline care or treatment (e.g., due to preferences, maintaining 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 IDT 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.

      • Record review – Is there evidence that the resident has refused any care or services that would otherwise be required, but are not provided due to the resident’s right to refuse treatment? If so, does the care plan reflect this refusal, and how the facility has addressed this refusal? Is there evidence that care plan interventions were implemented consistently across all shifts?
  1. Ensure real-time revision

The comprehensive care plan must be reviewed and revised “after each assessment,” meaning, after each MDS, but standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. In other words, a fall, newly identified skin issue, new medication, or diagnosis for example, should trigger the IDT to review and revise the plan of care at the time of the event and not be delayed until the next MDS assessment becomes due. Residents’ preferences and goals may change throughout their stay, so ongoing discussions should be had with the resident and/or resident representative so that changes can be reflected in the comprehensive care plan.

      • Record review – How did the resident respond to care planned interventions? Was the care plan revised if interventions weren’t effective, the desired outcome was achieved, or if there was a change in condition?

Additional consideration: Revise ADL care plans to reflect neutral terminology. Beginning October 1, 2023, Section G will be removed from the MDS and Section G-specific terminology will no longer be current in the plan of care. More descriptive, individualized terms and/or phrases will better represent the resident’s ability and align with Section GG assessment data and goal setting. For example, instead of “extensive assistance,” weight-bearing assistance can be described by the amount of effort provided by the helper (more or less than half) and the assistance needed (e.g., supports trunk or limbs).

Join Proactive on April 11, 2023, for the Deep Dive into Federal Regulations session: §483.20 Resident Assessment & §483.21 Comprehensive Person-Centered Care Plan Requirements. This session will provide an overview of the Resident Assessment and Comprehensive Person-Centered Care Plans regulations at §483.20 and §483.21, with an emphasis on the review of the most commonly cited resident assessment and comprehensive care plan requirements. Strategies to avoid citations related to resident assessment and comprehensive care plans will be emphasized through discussion of actual citation examples, strategies for successfully managing the survey process & understanding the critical element pathways used to guide surveyor investigations, & implementing survey preparedness activities to prevent resident assessment and comprehensive care plan citations. Contact Proactive to schedule an objective care plan and clinical documentation review as part of your QAPI survey readiness work plan.



Written By: Eleisha Wilkes, RN, GERO-BC, RAC-CT, DNS-CT
Clinical Consultant

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