1. DEVELOPING A COMPREHENSIVE CARE PLAN PRESENTED BY LEAH KLUSCH EXECUTIVE DIRECTOR THE ALLIANCE TRAINING CENTER

2. WHAT IS THE REQUIREMENT ?  Start with the Tags – regulations and the directions from the RAI Manual  Tag 279 says – The facility must use the results of the assessment to develop, review and revise the comprehensive plan of care.  The facility must develop a comprehensive care plan for each resident that includes measureable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial well being.  Any services that would otherwise be required under the tag but are not provided due to the resident’s exercise of rights to refuse treatment.

3. Guidelines in the regulatory requirements  The interdisciplinary team in conjunction with the resident, resident’s family or representatives should develop quantifiable objectives for the highest level of functioning the resident may be expected to obtain, based on the comprehensive assessment. The interdisciplinary team should show evidence in the CAA summary or clinical record of the following:  Resident’s status in triggered CAA areas  Facilities rationale for deciding to proceed with care planning and  Evidence that the facility considered the development of care planning interventions for all CAAs triggered by the MDS.

4. TAG - 280  The resident has the right to participate in planning care and treatment or changes in care and treatment.  “Participates in planning care and treatment” means that the resident is afforded the opportunity to select from alternative treatments when possible. This must be documented.  The comprehensive care plan must be:  Developed within 7 days after the completion of the comprehensive assessment.  Prepared by an interdisciplinary team that includes the physician, registered nurse 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 and other representatives.

5. TAG 281  The services provided or arranged by the facility must meet professional standards of quality  “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 of care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency.

6.  Possible reference sources for standards of practice include:  Current manuals or textbooks on nursing, social work, physical therapy etc.,  Standards published by professional organizations or associations  Clinical practice guidelines published by the Agency of Health Care Policy and Research  Current professional journal articles

7. THE CARE PLAN MUST CONNECT TO THE ASSESSMENT AND THE SERVICES THE FACILITY IS DELIVERING.  This includes all the services being delivered – Nursing and Rehab  Rehab plan and the care plan must be related  Must meet standards of practice  Must be documented including outcomes  Plan must be a true reflection of the Assessment

8. SO WHAT HAPPENS WHEN……….  The resident is getting rehab and has a very low ADL score on the assessment.  The assessment shows no deficit in cognition and Speech Therapy is treating 4 or 5 days a week for cognitive issues.  The test for balance in Section G shows no deficit and the physical therapy goal is to reverse a deficit in balance.  The resident reports significant levels of pain but is still getting very long therapy treatments every day.  The CATs show deficit in ADL’s or cognition and the resident is not getting therapy or interventions.

9.  This is why the comprehensive care plan must include all the services the resident is getting and it must be consistent across all departments. So the Plan of Care in Therapy must be part of the overall Comprehensive Care Plan.  Read Chapter 4 of the RAI Manual for the specifics on the requirements to connect the Assessment to the Care Plan and the Documentation requirements.

10. When is the Care Plan Complete ?  Very important documentation for the Section V completion.  Be very careful that you do this carefully with dates and documentation of the Care Conference attendance sheet.  Section V directions in the RAI Manual – Chapter 3 are very important and can become high risk citation items.  Many of the facilities do not document Section V item 0200C 1 and 2 properly.  This date must be the day of or after the Care Conference Meeting that is documented in the medical record.  Then the comprehensive assessment is complete and can be transmitted – not before that date.

11. MANY CHANGES AND NEW ISSUES WITH CARE PLANNING  GO BACK AND SEE WHAT THE PROCESS IS TO INCLUDE REHAB SERVICES AND GOALS INTO THE CARE PLAN  MAKE SURE THE GOALS FOR ALL THE CARE ARE CONSISTENT AND DELIVERABLE.  RESPECT STANDARDS OF PRACTICE FOR ALL SERVICES.  DOCUMENT THE DATE OF THE CARE PLAN CONFERENCE IN THE RECORD AND SIGN SECTION V OF THE ASSESSMENT PROPERLY.  TRANSMIT THE ASSESSMENT AFTER THE CARE PLAN IS COMPLETED AND DATE SECTION V0200C1,2 PROPERLY.