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8/17/2017
1
PERSON-CENTERED
CARE PLANS
WENDY BOREN, BS, RN, REGION 2
CAROL SIEM, MSN, RN, BC, GNP, RAC-CT REGION 7QIPMO
Clinical Consultants/Quality Educators
Sinclair School of Nursing
COMPREHENSIVE RESIDENT CENTERED CARE PL AN
• 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)
F TAG 279 BASELINE CARE PL AN
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.
BASELINE CARE PL AN
• 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 PL AN
• 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.
BASELINE CARE PL AN
• 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
8/17/2017
2
F 279 §483.21(B) C O MPREHENSIVE C ARE P L ANS
• (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 —
F 279 §483.21(B) C O MPREHENSIVE C ARE P L ANS
• (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) C O MPREHENSIVE C ARE P L ANS
• (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
SURVEYOR PROBES
• 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.
8/17/2017
3
F 280 §483.21( B) C O MPREHENSIVE C ARE
P L ANS
• §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.
PROBES
• 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
• 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?
F281
• (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
• §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)]
F282
• 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?
8/17/2017
4
D I S CH A RG E
P L A N N I N G
RE Q U I RE ME N TS
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.
GUIDANCE for DISCHARGE
DISCHARGE PL ANNING (IN CARE PL ANS)
– § 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 PL ANNING (IN CARE PL ANS)
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;
D ISCHARGE PL ANNING ( IN CARE PL ANS), CONT ’D
• 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.
DISCHARGE PL ANNING (IN CARE PL ANS)
• …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.
8/17/2017
5
F TAG 283
• (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).
F TAG 284
• (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
• 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.
F TAG 284 (CONT)
(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) D I SCHARGE S UMMARY
• 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 post-
discharge 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 post-
discharge medical and non-medical services.
PROBES
• 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?
8/17/2017
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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.
Comprehensive Care Plan F656 §483.21(b)
“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
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.
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 KnowR E S I D E N T R I G H TS
483.10 RESIDENT R IGHTS
• 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.
483.10 RESIDENT R IGHTS
• 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.
8/17/2017
7
483.10 R ESIDENT R IGHTS
• 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.
483.10 R ESIDENT R IGHTS
• 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 R IGHTS
• 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 RI TI N G A N D
I N CL U S I O N
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.
8/17/2017
8
COMPREHENSIVE CARE PL ANS
• 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
COMPREHENSIVE CARE PL ANS , BY CMS
• 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
• 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 (FORMERLY F242)
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.
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
Sample Care Plan Meeting Summary
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
8/17/2017
9
CARE PL AN 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.”
CARE PL AN WRITING AND INCLUSION• Assessment
– 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…”
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.
CARE PL AN WRITING AND INCLUSION
Typical Care Plan
Problem Goal Intervention
8/17/2017
10
CARE PL AN WRITING AND INCLUSION
Category Requirements Preferences Inclusion
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.
CARE PL AN WRITING AND INCLUSION
Narrative “I” Care Plan
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 PL AN 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 PL AN 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
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.
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.
GUIDANCE for PASRR
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
8/17/2017
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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)
• This includes dually certified beds (both Medicare and Medicaid)
PASRR
• Behavioral is defined as an individual’s social or metal activities
• Applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or
others must be transferred immediately to an appropriate facility
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.
PASRR
• 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
• 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
LEVEL II SCREENING
• 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
8/17/2017
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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 ETI N G S
CARE PL AN 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 PL AN 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 PL AN 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
CARE PL AN MEETINGS
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PERSON-CENTERED CARE PL AN 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 RV E Y O RS
WA N T T O 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?
• 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?
Surveyor Questions
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.
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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
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.
CMS Manual System Transmittal Pub. 100-07 State Operations Provider Certification-169-Advanced copy. Pages
205-210
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 …
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