COMPREHENSIVE PERSON CENTER CAREPLANNING

P H A R M C A R E O K

5 1 0 A R A P A H O A V E .H Y D R O , O K 7 3 0 4 81 - 8 6 6 - 4 0 3 - 2 0 0 3

P R E S E N T E R :T E R R I E G O R D O N R N

COMPREHENSIVE AND PERSON CENTERED CAREPLANS

LEARNING OBJECTIVES

Learning Objectives

• New and practical way of looking at care planning

• Explain how to have hands-on care partners involved in every step of the care planning process

• Understand how the changes discussed will involve your own residents more deeply in their own care

DEFINITION OF PERSON CENTERED CARE

• … definition of

‘‘person- centered care’’ to be defined as focusing on the resident as the locus of control and supporting the resident in making their own choices and having control over their daily lives

CULTURE CHANGE VS MEDICAL MODEL

• Moving away from the medical model of schedules regarding personal care, medication administration, environment of facilities, dining options, other areas to provide a home like experience.

• Medical model focuses on the illness and disease processes rather than the elders and what is important to them.

COMPREHENSIVEPERSON-CENTEREDCAREPLANNING(§483.21)PREVIOUSITEMS

ü Comprehensive care plans was within the Resident Assessment

regulatory set at §483.20

ü Did not include “Person-centered” the title

ü With the exception of the Resident Assessment requirements,

all previous subsections of §483.20 were re-designated to this

new regulatory section

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)KEY REQUIREMENTS

The facility must develop and implement a baseline care plan for

each resident that includes the instructions needed to provide -

Ø Effective and person-centered care for the resident that meets

professional standards of quality care

Ø Must be developed within 48 hours of a resident’s admission

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)KEY REQUIREMENTS

Ø Any services and treatments to be administered by the facility and

personnel acting on behalf of the facility

Ø Any updated information based on the details of the

comprehensive care plan, as necessary

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)KEY REQUIREMENTS

The facility must develop and implement a comprehensive

person-centered care plan for each resident, consistent with the

residents rights that—

Ø Meet their medical, nursing, mental and psychosocial needs

(identified in their comprehensive assessment)

Ø Must include measurable objectives and timetables for goal

accomplishment

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)KEY REQUIREMENTS

…and must describe—

Ø The services that are to be furnished to attain or maintain the

resident’s highest practicable physical, mental, and psychosocial

well-being…..and….

Ø Any services that would otherwise be required under the

quality of life and/or behavioral health services regulation but

are not provided due to the resident’s exercise of rights

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)KEY REQUIREMENTS

Ø Any specialized services or

rehabilitative services resulting from

the PASARR recommendations

• If a facility disagrees with the

findings of the PASARR, you must

indicate its rationale in the resident’s

medical record

KEY REQUIREMENTS

Ø Prepared by an interdisciplinary team, that minimally includes:

o Attending physician

o Registered nurse with responsibility for the resident

o Nurse aide with responsibility for the resident

o Member of food and nutrition services staff

o Social worker (not required in final rule, but, good practice when included)

o Other appropriate staff or professionals in disciplines as

determined by the resident’s needs or as requested by the resident

KEY REQUIREMENTS

The services provided or arranged by the facility must—

² Meet professional standards of quality

² Be provided by qualified persons

² Be culturally-competent and trauma-informed

KEY REQUIREMENTS (COMING)

Culturally-competent and trauma-informed care are approaches

that help to minimize triggers and re-traumatization.

◦ Care that addresses the unique needs of Holocaust survivors and

survivors of war, disasters, and other profound trauma are an

important aspect of person-centered care for these individuals.

KEY REQUIREMENTS (DISCHARGE PLANNING)

Discharge Planning

Ø The facility must develop and implement an effective discharge

planning process, focusing on—

o The residents discharge goals

o Preparing them to be active partners and effectively transition

them to post-discharge care

o The reduction of factors leading to preventable readmissions

o Ensuring their discharge rights are honored

KEY REQUIREMENTS (DISCHARGE PLANNING)

The facility’s discharge planning process must—

ü Ensure that the resident’s discharge needs are identified and result

in the development of a discharge plan for the resident

ü Include regular re-evaluation to identify changes which require

modification of the discharge plan

ü Involve the interdisciplinary team in the ongoing process of

developing the discharge plan

KEY REQUIREMENTS (DISCHARGE PLANNING)

ü Consider caregiver/support person availability and capability to

perform required care as part of the identification of discharge

needs

ü Involve the resident and resident representative in the

development and inform them of the final plan

ü Address the resident’s goals of care and treatment preferences

KEY REQUIREMENTS

ü Document that a resident has been asked about their interest in

receiving information regarding returning to the community—

q Must update the resident’s comprehensive care plan and

discharge plan in response to information received from

referrals

q If discharge to the community is determined to not be feasible,

you must document…

KEY REQUIREMENTS (DISCHARGE)For residents who are being transferred to another SNF or will bedischarged to a HHA, IRF, or LTCH, you’ll need to assist them inselecting a PAC (POST ACUTE CARE) provider by using data that includes, but is notlimited to:• SNF, HHA, IRF, or LTCH standardized patient assessment data• Data on quality measures• Data of resource You will need to ensure that the post-acute care data is relevant andapplicable to the resident’s goals of care and treatment preferences.Ø The data presented is not intended to recommend facilities, but ratherpresented in order to assist residents/families in making informeddecisions regarding the selection of a post-acute care providerØ must be based on the individual goals and preferences of theresident

KEY REQUIREMENTS (DISCHARGE SUMMARY)

When the discharge of a resident is anticipated, a discharge

summary must be documented and provided to the resident that

minimally includes—

• A recapitulation of their stay

o Diagnoses

o Course of illness/treatment or therapy

o Pertinent lab, radiology, and consultation results

KEY REQUIREMENTS (RESIDENT ASSESSMENT)

• With the consent of the resident or

resident’s representative, a final

summary of the resident’s status

(Resident Assessment) be available for

release to authorized persons and

agencies.

• Medications a resident was

prescribed when leaving the facility

PHASE 1,2,3

Comprehensive Person-centered Care Plans•Phase 1: November 28, 2016Except for –Baseline Care Plan• Phase 2: November 28, 2017Trauma Informed Care• Phase 3: November 28, 2019

FEDERAL/STATE REGULATIONS

S T A T E : 4 8 3 . 2 1F E D E R A L : 2 7 9 , 2 8 0 , 2 8 1 & 2 8 2• C O M P R E H E N S I V E• M E A S U R A B L E G O A L S / T I M E F R A M E S• I N T E R D I S C I P L I N A R Y• P E R I O D I C A L LY R E V I E W E D / R E V I S E D• M E E T S P R O F E S S I O N A L S T A N D A R D S• C A R E I S P R O V I D E D B Y Q U A L I F I E D

S T A F F

COMPREHENSIVE PERSON-CENTERED CARE PLANNING

WHY THE CHANGES:

Safe trans across care settingSafely reduce hospital readmissions and

unnecessary hospitalizations

COMPREHENSIVE PERSON-CENTERED CARE PLANNING KEY WHAT IS REQUIRED NOW..

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 for the resident that meets professional standards of quality care

Must be developed within 48 hours of a resident’s admission

COMPREHENSIVE PERSON-CENTERED CARE PLANNING KEY REQUIREMENTSSummary of the baseline care plan includes;

v The initial goals of the resident

v A summary of the resident’s medications and dietary instructions

COMPREHENSIVE PERSON-CENTERED CARE PLANNING (§483.21)REQUIREMENTSv Include the minimum healthcare information necessary to properly care for a

resident including, but not limited to:

Initial goals based on admission orders

Physician orders

Dietary orders

Therapy services

Social services

PASARR (if applicable)

RECOMMENDATIONS CONT.

Any services and treatments to be administered by the facility and personnel acting on behalf of the facility

Any updated information based on the details of the comprehensive care plan, as necessary

AND

Any specialized services or rehabilitative services resulting from the PASARR recommendations

If a facility disagrees with the findings of the PASARR, you must indicate its rationale in the resident’s medical record

CAREPLANS

After consultation with the resident and the resident’s representative, the comprehensive care plan must describe;

The resident’s goals for admission and desired outcomes

The resident’s preference and potential for future discharge

Discharge plans (as appropriate)

RULES OF CAREPLAN A comprehensive care plan must be developed—

Within 7 days after completion of the comprehensive assessment

After each assessment (includes both the comprehensive and

quarterly reviews), the care plan must be reviewed and revised by

the interdisciplinary team

Prepared by an interdisciplinary team, that may include:

Attending physician

Registered nurse with responsibility for the resident

Nurse aide with responsibility for the resident

Dietary staff

Social worker

MDS Coordinator

Hospice

Therapy staff

Restorative staff

CAREPLANS

CMSdoesnotrequirethatanyofthemembersoftheIDT

participateinperson!Youcanhavethecareplan meetingoverthephone.

IDT members do not have to attend they may used electronic or discussion to participate.

CAREPLAN MEETINGSWHO ATTENDSNeed to include the participation of the resident and the resident’s

representative(s) in the care planning process

Need to have signature or summary in the chart of the careplan meeting and who attended. If the family is unable or refuses to attend you need to note and try to keep them informed of residents care.

If the resident is unable to attend they still need

To keep resident informed.

CAREPLANWHO CAN PROVIDEThe services provided or arranged by the facility must—

Meet professional standards of quality

Be provided by qualified persons

Be culturally-competent and trauma-informed

DISCHARGE PLANNING CAREPLAN

DischargePlanning

The facility must develop and implement an effective discharge

planning process, focusing on:

1. The residents discharge goals

2. Preparing them to be active and effectively transition them to post-discharge care

3. Reducing factors that lead to preventable readmissions4. Ensuring discharge rights are honored

DISCHARGE PLANNING

Thefacility’sdischargeplanningprocessmust—q Ensure that the resident’s discharge needs are identified and

result in the development of a discharge plan for the residentq Re-evaluation to identify changes which require modification of the

discharge planInvolve the IDT in developing the discharge planCaregiver/support person availability and capability

Involve the resident and resident representative in the development and inform them of the final plan

Document that a resident has been asked about their interest in receiving information regarding returning to the community

CAREPLANS

You will need to ensure that the post-acute care data is relevant and applicable to the resident’s goals of care and treatment preferences.

The data presented is not intended to recommend facilities

Data must be based on the individual goals and preferences of the

resident

Facilities will need to demonstrate compliance with this requirement by

showing evidence that the relevant data was presented

DISCHARGE DOCUMENTATION

Your documentation of the resident’s discharge needs and subsequent discharge plan must be complete and timely.

RECORD MUST REFLECT:

You discussed the results of the evaluation with the resident and family

All relevant resident information was incorporated into the

discharge plan to avoid delays

PHASE

ComprehensivePerson-centeredCarePlans

2016: Phase 1: November 28, 2016

Baseline Care Plan

2017: Phase 2: November 28, 2017

Trauma Informed Care

2019: Phase 3: November 28, 2019

WHAT SURVEYORS LOOK FOR.• R E S I D E N T N E E D S• S T R E N G T H S • P R E F E R E N C E S I D E N T I F I E D I N T H E M D S .• C P O R I E N T E D T O W A R D P R E V E N T I N G

A V O I D A B L E D E C L I N E S• M A N A G E R I S K F A C T O R S

SURVEYORS CONT’

• TREATMENTS HAVE OB JECT IVE MEASURABLE OUTCOMES

• CORROBORATE INFORMATION REGARDING THE RES IDENT ’ S GOALS AND WISHES FOR TXIN THE POC BY INTERV IEWING , ESPEC IALLY REFUS ING TREATMENT. DOES THE FAC I L I TY F IND ALTERNAT IVE WAYS WHEN RES IDENT REFUSES CARE .

SURVEYORS CONT’

Can direct care staff describe the care, services and expected outcomes of the care they provide.

Is the care plan revised when the resident status changes?

In what ways do staff involve residents and families, in care planning.

CAA’S & CAT’S

• CAAS ARE FURTHER IN -DEPTH OF 20 TR IGGERS (CATS ) THAT MAY IMPACT THE RES IDENT.

• EACH TR IGGERED AREA MUST BE INVEST IGATED AND MAKE A CARE P LANNING DEC IS ION .

• THIS INFORMATION SERVES AS BAS IS TO FOR A P LAN OF CARE FOR THE RES IDENT .

CAAS & CATS

• TR IGGERS ARE F LAGS THAT REQUIRE FURTHER INVEST IGAT ION .

• S0ME AREAS MAY OR MAY NOT TR IGGER AND SHOULD BE CARE P LANNED. SUCH AS ADL’ S ; ADL’ S DO NOT ALWAYS TR IGGER ; SO EVEN I F SOMETHING DOES NOT TR IGGER I T I S YOUR CHOICE WHETHER OR NOT TO CARE P LAN .

SECTION V

CARE PLANNING GUIDELINES

• CARE PLAN MEETING NEED TO BE SCHEDULED AT THE BEST TIME OF DAY FOR THE RESIDENTS AND THEIR FAMILIES.

WHO IS RESPONSIBLE FOR THE CAREPLAN

• N U R S I N G I S T H E K E Y P E R S O N I N E N S U R I N G P O S I T I V E O U T C O M E S F O R T H E R E S I D E N T S .

• A N Y O N E W H O I S D I R E C T C A R E C A N R E A D T H E C A R E P L A N A N D P R O V I D E C O M M E N T S T O T H E C A R E P L A N S TA F F.

• A N R N I S O V E R A L L R E S P O N S I B L E I F T H E L P N I S T H E M D S C O R D .

NURSING PROCESS

1 . A S S E S S M E N T ( C O L L E C T I O N O F D A T A )2 . P R O B L E M I D E N T I F I C A T I O N

( A N A LY S I S A N D I N T E R P R E T A T I O N O F D A T A )

3 . P L A N N I N G ( P R I O R I T I Z I N G N E E D S , I D E N T I F Y I N G G O A L S , C H O O S I N G I N T E R V E N T I O N S )

4 . I M P L E M E N T A T I O N ( P U T T I N G T H E P L A N I N T O A C T I O N )

5 . E V A L U A T I O N ( A S S E S S I N G T H E E F F E C T I V E N E S S O F T H E P L A N A N D M A K I N G C H A N G E S A S N E E D E D )

GATHERNING CARE PLAN INFORMATION

• P R I M A R Y S O U R C E I S T H E R E S I D E N T• T A L K W I T H F A M I LY, F R I E N D S , S I G

O T H E R S• T A L K W I T H S T A F F O N A L L S H I F T S• T H E P H Y S I C I A N• L O O K A T O R D E R S , H O S P I T A L H I S T O R Y• L O O K A T C O N S U LT A N T R E P O R T S S U C H

A S : D I E T A R Y, P H A R M A C Y E T C .• L A B R E P O R T S , X R A Y R E P O R T S• 2 4 H O U R R E P O R T S• I N C I D E N T R E P O R T S

WHAT IS A CARE PLAN?

• I T I S A D O C U M E N T E D I N D I V I D U A L I Z E D R O A D M A P T O R E C O V E R Y A N D P R E V E N T I O N O F F U R T H E R D E C L I N E .

• I T I S T H E N U C L E U S T H A T I D E N T I F I E S A N D G E N E R A T E S A L L P R O C E S S I N V O L V E D W I T H R E S I D E N T C A R E .

• I T I S A L L A S P E C T S O F T H E R E S I D E N T S H E A LT H A N D S E N S E O F W E L L B E I N G .

• I T E S T A B L I S H E S A C O U R S E O F A C T I O N T H A T M O V E S A R E S I D E N T T O W A R D A S P E C I F I C G O A L U T I L I Z I N G I N D I V I D U A L R E S I D E N T S T R E N G T H S A N D E X P E R T I S E .

• I T ’ S T H E H O W O F R E S I D E N T C A R E .

WHY IS A CARE PLAN IMPORTANT?

• I T I S D O C U M E N T E D P R O O F O F T H E E F F O R T T O P R E V E N T A V O I D A B L E D E C L I N E .

• I T I S A M E C H A N I S M F O R R E S O L U T I O N O F C U R R E N T P R O B L E M A R E A S A N D C O N C E R N S .

• I T I S A M E C H A N I S M U T I L I Z E D T O P R E V E N T A N D A V O I D N E W P R O B L E M A R E A S A N D C O N C E R N S .

• I T P R O V I D E S A S O L U T I O N - O R I E N T E D , D Y N A M I C P R O C E S S A N D B E C O M E S A P R A C T I C A L M E A N S O F H E L P I N G F A C I L I T Y / S T A F F G A T H E R I N F O R M A T I O N T O I M P R O V E A R E S I D E N T S Q U A L I T Y O F L I F E / C A R E .

“GOALS”

• G O A L S M U S T B E R E A L I S T I C A N D M E A S U R A B L E

• D E F I N E A T I M E F R A M E F O R A C H I E V E M E N T.

• I D E N T I F Y R E S I D E N T D E S I R E S A N D R E S O U R C E S

• S H O U L D N E V E R I N C L U D E N E V E R , A L W A Y S , W I L L H A V E N O , B E F R E E O F E T C .

• S H O U L D I N C L U D E R E D U C E D , D E C R E A S E D , M I N I A M A L , M A I N T A I N E T C .

• M R S . S M I T H W I L L H A V E D E C R E A S E O F 1 0 F A L L S T O N O M O R E T H A N 2 O V E R T H E N E X T 3 0 D A Y S .

“APPROACHES”

• A P P R O A C H E S A R E T H E D I R E C T I O N S F O R T H E S T A F F A N D O T H E R S T O A S S I S T T H E R E S I D E N T I N M E E T I N G T H E I D E N T I F I E D G O A L S .

• N E E D T O B E R E A L I S T I C A N D D O A B L E .• M A K E S U R E T H A T T H E A P P R O A C H E S

A R E W H A T I S B E I N G D O N E B Y T H E S T A F F. S U R V E Y O R S W I L L R E A D T H E C A R E P L A N A P P R O A C H E S A N D T H E N C H E C K T O S E E I F S T A F F O R C A R R Y I N G O U T T H E A P P R O A C H E S .

• D O N O T P U T: B A T H M - W - F I N S T E A D U S E B A T H 3 T I M E S A W E E K , E T C .

“I-CARE PLANS”

1

Hillcrest Living Center Resident Care Guide Review Date: Next review date: Name: Room #: Address me as: DOB: Allergies: Code Status: DNR Long Range Goal: To live the remainder of my life with dignity, to my fullest potential, in a safe and comfortable environment. Social History: I was born on September 30, 1930 in Waldo Township. I grew up in Gridley and moved to Roanoke when I was married. My husband, John and I have five children. I was a homemaker and a secretary. I enjoyed sewing. Nursing Concerns: I have schizoaffective disorder and Parkinson's disease that severely affect my ability to care for myself. Observe me for indications of distress or discomfort and intervene as needed. My goal is: Communication / Memory: Vision: My vision appears adequate with glasses, however, I no longer read because I am unable to concentrate and remember what I am reading. I will not answer questions regarding my vision because I feel that you are trying to hypnotize me. Hearing/Communication: My hearing is adequate, however, when communicating, I become very anxious and may be slow to respond. Often I will not respond verbally. Allow plenty of time for me to process what you have said to see if I will respond. Memory: I have an altered perception of the way things are. I also state that I have trouble remembering things and that my concentration is poor. Assist me as needed if I need reassurance. My goal(s): Psychosocial: Mood/Behaviors: I have a history of being unnecessarily suspicious of my family and staff. I have had this difficulty for many years and take medication to assist me and also see a psychiatrist routinely. I have Schizoaffective disorder. This causes me to have delusional thoughts which cause me to become fearful. Staff should approach me slowly and gently. I respond better if staff takes a slow, loving, reassuring approach in helping me with my cares. My goal is:

“Resident Name” – Resident Care Guide Mobility: Ambulating: I am unable to ambulate and use a wheelchair for all mobility. Transfers: I need the assist of 2 to transfer. Be aware that I may not put any weight on my feet at times. Positioning: Assist me to reposition every two hours and as needed. Assistive Devices: wheelchair My goal(s):

“I- CARE PLANS”“Resident Name” – Resident Care Guide

Mobility: Ambulating: I am unable to ambulate and use a wheelchair for all mobility. Transfers: I need the assist of 2 to transfer. Be aware that I may not put any weight on my feet at times. Positioning: Assist me to reposition every two hours and as needed. Assistive Devices: wheelchair My goal(s): Therapy Services: Please perform range of motion to all my extremities twice a day, 7 days a week, to maintain range of motion and promote comfort. It is harder to do range of motion on my left wrist than in the past. My wrist may jerk while performing range. My goal is: Personal Care: Oral: Brush my teeth twice daily. AM & PM Care: I am dependent on you for my partial baths. Dressing: Encourage me to pick out my own clothing if my condition allows. I need extensive assist to dress. I may lift my arms into sleeves and may try to lift my right leg. Toileting: Take me to the toilet if my condition allows. Do not leave me, as I will fall. I wear full Attends incontinent briefs. Check and change them every two hours and as needed. Observe my skin with care and report any signs of breakdown. Report to nurse any complaints of constipation. Bathing: I take a tub bath as scheduled. My hair is done weekly in the beauty shop. My goal is to be well groomed and odor free. Skin: My skin is intact at this time. Encourage me to lie on my side to prevent pressure areas from developing on my coccyx. I wear a brace on my left hand/wrist that is to be worn at night. Observe my hand/wrist for increased swelling and poor circulation and remove the brace if needed. My goal is for my skin to remain without complication over the next 3 months. Safety Notes/Falls: I take medications that may cause side effects such as dizziness, etc. Observe my sitting position and intervene as needed to keep me safe. Use a TABS monitor to alert staff of attempts to transfer myself or of unsafe position. My goal is: Nutrition: Diet: I receive a regular, mechanical soft diet with 4 oz. house supplement at 3 p.m. with super cereal in the a.m. I also receive 4 oz. of extra juice with meals. My goal is to gain 1-2# per month in the next 3 months. My current weight is . Habits: I may c/o trouble swallowing (I exhibit no symptoms). Please encourage me to eat what I can. My husband feeds me as I will allow. I will sit in a wheelchair at meals. My husband is here often at meal time to assist me in any way he can.

“I-CARE PLANS”RIVERVIEW CARE CENTER RESIDENT CARE PLAN

NAME: Jane Doe ROOM#: 344 DATE: 11/20/04 ADDRESS ME AS: Jane or Mrs. Doe BIRTHDATE: 5/15/1915 ADMIT DATE:11/01/03 SOCIAL HISTORY : I was born in Minnesota in 1915. At a young age I moved west with my family. We settled in Tekoa, Washington where we lived on a large farm. My mother and father managed the farm while my brother and I attended school. My parents always valued a good education. I graduated from high school in Tekoa during the Great Depression. To attend school I moved to the “big city” of Seattle. In the city I attended Washington State College. To pay my way, I went to work as a model. My Seattle modeling career only lasted for 5 years but I had a very enjoyable time at it. “The things I learned in that job lasted me a lifetime.” After moving to Spokane to be closer to my family, I worked as a model for “Bernard’s” which was a big department store back then. In 1940 I married my first husband. He was an established dentist in the Spokane community. We raised two children, a boy and a girl. After my husband’s death in 1955, I remarried. My second spouse was a land developer. We enjoyed our life together until his death two years ago. My 2 children, 3 grandchildren and seven great grandchildren all live nearby. They visit often and I enjoy their companionship. 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 or fashion, I would love to share my opinion. I especially like to comment 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. WELL-BEING: Most of the time my mood is very pleasant. I enjoy people, I enjoy talking, and I look forward to the daily visits from my daughter. She brings in the grandkids and her little dog most of the time. Looking forward to her visits gives me hope and keeps me from being lonely. She comes in the early afternoon. Sometimes in the morning around 10:00 I start to miss her. Take a few moments to talk with me And remind me of her schedule. I especially like to spend the morning on Thursday with the daycare kids to pass the time while I wait for her.

I am not helpless. The thing that makes me happiest is when I am in control of the things going on around me. You can help by offering me choices in my care. Encourage me to get out and be with others. It is important that I get to all three meals in the dining room because my table companions count on me to be there. If I appear grouchy, really listen to me. I like to have things done my way so follow my directions. I also get grouchy if I am hurting in my back, hip or shoulder. I take medication that helps me with pain and with depression. Let my nurse know if I am feeling irritable, if I don’t want to get out of bed, if don’t feel like eating, or I don’t bother to put on my make-up. These are signs that I am not quite myself.

Looking good is critical in enhancing my mood. Don’t let me leave my room unless I am very well dresses and groomed. My daughter irons all my clothes and hangs them in coordinating sets in my closet to help you. My favorite color is red. For any parties or special events offer me a red outfit first.

GOAL: I want to make decisions in my life and daily care. I want my mood to improve with your helping interventions. (Measured by mood monitor). MOBILITY:

HOW TO REVISE/UPDATE THE CARE PLAN

The care plan must be periodically reviewed and revised, and the services provided or arranged must be in accordance with each resident plan of care.

The care plan must reflect a holistic, accurate and CURRENT approach to resident care.

REVISE/UPDATE CONT.

A new care plan does NOT need to be developed;

-After a SCSA

-After Significant Correction of Prior Full Assessment

-For an annual assessment

-however the cp must be reviewed and evaluated for appropriateness after each quarterly assessment and upon readmission.

REVISE/UPDATE CONT

The care plan must be revised on an on going basis to reflect changes in the care the resident is receiving.

Review new orders, progress notes, consultant reports, fall reports, skin assessments, prior month physician recap orders to revise the care plan.

REVISE/UPDATE CONT

Leave sufficient room between goals to facilitate revisions.

Draw a line through statements which no longer apply and date the revision.

Accommodate revisions and changes if one problem area or concern per care plan page.

DON’TS FOR CARE PLANSDo not reprint the care plan every time it is revised. Only print brand new care plan

for admission, annual or significant change

Delegate staff member to revise/update care plans.

Don’t use CANNED or GENERIC problems, goals and approaches

Don’t repeat the same problem over and over again.

DO’S

Show a process with frequent revisions and updates.

Conduct facility audits of care plans.

Make sure all disciplines are addressed on the care plan

Document resident strengths

Leave room on care plan to make it a working care plan for revisions/updates.

DO’S

One care plan problem per page

Include care planning as part of your nursing orientation

Share with CNA’s what the care plan says

Put care plans in a location for staff review

MEDICAL MODELMEDICAL MODEL:

-STAFF KNOW YOU BY DX

-STAFF WRITE CARE PLAN BASED ON WHAT THEY THINK IS BEST FOR YOU DX.

-INTERVENTIONS ARE BASED ON STANDARDS OF PRACTICE PER DIAGNOSIS

MEDICAL MODEL

-Care plan written in the third person

-Care plan attempt to fit resident into facility routine

-Care plan scheduled at facility convenience.

COMMUNITY MODEL

-Care plan written in first person “I” format

-Care plan identifies resident’s lifelong routine and how to continue it in the nursing home

-Nursing assistants are valuable part of care plan conference.

-Care conference scheduled at resident and family convenience.

CHANGING THE CULTURE OF CARE PLANNING-Staff have personal relationship with resident and family

-Resident, family and staff develop care plan that reflects what resident desires for him/her

Unique interventions which meet the needs of that resident.

QUESTIONS?

How will you demonstrate the baseline care plan was developed

within 48 hours of a resident’s admission?

Do you currently have a process for providing a summaryof the

baseline care plan is to the resident/representatives in a manner

that they can access and understand? Electronic charting?

Will you have to develop or revise a policy/procedure related to

method of care planning participation?

How will demonstrate participation in care planning to reflect

inclusion of the CNA and food/nutrition services staff?

QUESTIONS

Will you have to develop or revise informational material for

resident/representative for rights related to participation in the

care planning process, determining who will represent them?

What about the “services that would otherwise be required

under the quality of life and/or behavioral health services

regulation but are not provided due to the resident’s exercise of

rights”? Might need to add this to your policy/procedure on care

planning? - including the part if you disagree with the findings of

the PASARR.

QUESTIONS

Documenting whether the resident’s desire to return to the

community was assessed; and any referrals to local contact

agencies and/or other appropriate entities - ??? Policy revision

Will you have to develop or revision forms for baseline CP for copy

to resident, discharge summary/instructions for resident that also

reflects participation by resident/representative?

Section Q of the MDS – does your process already include this data

into the care planning?

QUESTIONS

If the resident indicates an interest in returning to the community,

do you already document any referrals to local contact agencies or

other appropriate entities made for this purpose, or is this a policy

development?

If discharge to the community is determined to not be feasible, the

facility must document whomadethedeterminationandwhy,

Policyrevision?

QUESTIONSHow will you assist residents and their resident representatives in

selecting a PAC provider by using data? and, who/where will this be

documented to demonstrate compliance with this requirement by

showing evidence that the relevant data was presented?

How will you incorporate obtaining the consent of the resident or

resident’s representative, a final report of the resident’s status

(Resident Assessment) so that it is available for release to the next

PAC provider or even the resident’s physician?

THE END!!!

QUESTIONS!!!