Care planning is an essential part of quality patient care as it offers an organized structure of identification of needs via the comprehensive assessment. This structure then drives the individualized type of services and care the resident receives by the development of the person-centered care plan. Think of the care plan as a road map that navigates the person-centered care that will be provided by your facility’s care team with the resident in the driver’s seat.

Items to Address Within Care Plan

The comprehensive care plan should address the goals, preferences, needs, and strengths of the resident, including those identified in the comprehensive resident assessment (at a minimum), to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline. Along with the comprehensive resident assessment, other screenings and assessment methods should be utilized in collaboration with residents, caregivers, IDT members, and families to develop the comprehensive care plan. Needed care or services should be addressed in the care plan including but not limited to nursing services, specialized rehabilitative services, behavioral health services, social services, dietary services, and pharmacy services, or activities according to the resident’s assessed individual needs. Risk factors for specific conditions and/or problems, preferences, choices, rights, advance directives, goals, physician orders, and professional standards of practice should all be considered. Additionally, discharge plans should be included reflecting the resident’s wishes to return to the community or not and if any referrals to local contact agencies and/or other appropriate entities were completed.

Person-Centered Objectives and Interventions

“Person-centered care means to focus on the resident as the locus of control and supports the resident in making their own choices and having control over their daily lives” (State Operations Manual, 2017).  Some examples include controlling choices such as daily routines including mealtimes, bedtimes, and activities, and clothing, etc. The resident’s goals or objectives should guide decision making during care planning along with address the resident’s medical, physical, mental, and psychosocial needs. Not only should goals be person-centered, but they should also be measurable including time frames to evaluate how staff is meeting the resident’s needs or desired outcomes. There should be an ongoing review of the resident’s progress towards goals and changes made to the care plan when goals are not met or new problems are identified.

There is no mandatory care plan format included in the interpretive guidance.  Some facilities may utilize “I” care plans, while some use CAA or problem/focus-based formats according to MDS responses or nursing diagnoses. The focus is not on the care plan format but rather the care plan reflects the resident’s assessment findings, goals, preferences, strengths, problems, and needs.

Resident and/or Representative Participation

There should be documentation present in the medical record that the resident and/or resident representative (if applicable) participates in developing the person-centered care plan. If the resident or representative chooses not to participate, facility attempts for participation should be documented. Adequate information should be provided to the resident and/or representative so that informed choices can be made regarding treatment and services.  Resident preferences and goals may change during their stay, so facilities should have evolving discussions with the resident and/or representative so that changes can be made to the care plan.

PASARR Recommendations

Residents covered by the Level II PASRR process with possible MI or ID/DD may require certain care and services provided by the nursing home, and/or specialized services provided by the State (Center for Medicare and Medicaid Services (CMS, 2019). The comprehensive care plan should include these specialized services and interventions to address PASARR recommendations including services the facility will provide or arrange. If the IDT disagrees with PASARR findings, documentation must indicate an explanation of the discrepancy between assessment needs and PASARR recommendations along with the benefits of alternate interventions. Also, if the resident selects a different approach, the medical record should specify the resident’s preference to achieve goals or refusal of services.

Care Plan Implementation

The implemented interventions should reveal consistency with resident needs, goals, and recognized standards of practice. Care plan interventions should be applied routinely throughout the entire day. The comprehensive assessment and other medical records and observations of the resident should mimic the care plan. For example, a resident is care planned for transfers using a Hoyer lift with two staff assisting. Noncompliance could be cited if day shift staff is observed manually lifting and transferring the resident even though night shift staff transferred correctly according to the care plan. As well, a process should be in place to ensure direct care staff are aware of and educated about the care plan interventions. The plan of care should be easily accessible to direct care staff also.

Refusal of Treatment

If a resident refuses treatment, the comprehensive care plan should reflect the facility’s efforts to find alternative means to address the care of the resident. Facility staff should make efforts to determine the reason(s) for the refusal. For example, a resident who is unable to verbalize their needs is refusing care. The staff determined that pain was a contributing factor and pain interventions were implemented.

Furthermore, the facility should inform and educate the resident regarding the risks/benefits of refusal and propose alternate choices. The facility must also plan to minimize further decline that could result in negative outcomes such as health and safety risks, certain conditions and/or problems. Additionally, the facility should assess the resident’s decision-making ability over time and contemplate when re-evaluating the care plan.

To assure compliance with F656, complete quality assurance audits by reviewing Care Area Assessment triggers and rational for proceeding with care plan or not and timely completion. Also, evaluate the care plan comparing documentation in the medical record and observations of the resident. The entire IDT team should communicate vital resident care information. Talk with the resident and CNAs to determine if the plan of care is person-centered with reflection of the resident’s choices and goals. Additionally, monitoring should entail reviewing revisions to the plan of care, PASARR specialized services, discharge plan, application of standard of practice and involvement of resident and/or resident representative.



Kristen Walden, MSN, RN, RAC-CT, Proactive Medical Review

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