02/24/2022

Survey Tip of the Week: Care plans and care plan conferences

Care plan citations were two of the top 10 most cited F-tags during the standard annual health inspection in 2019. F656 and F657 address development and timing of the care plan. At the beginning of the survey process, surveyors will interview residents to determine if they were part of their care plan and care plan conferences. For newly admitted residents, surveyors will ask the resident if they received a written summary of the baseline care plan. The baseline care plan is required to be developed and implemented within 48 hours of admission. The comprehensive care plan must be developed within seven days of the comprehensive assessment and after each assessment.

The State Operations Manual provides the following guidance related to care planning and care plan conferences:

Residents and their representative(s) must be afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions.  This applies both to initial decisions about care and treatment, as well as the refusal of care or treatment. Facility staff must support and encourage participation in the care planning process. This may include ensuring that residents, families, or representatives understand the comprehensive care planning process, holding care planning meetings at the time of day when a resident is functioning best, providing sufficient notice in advance of the meeting, scheduling these meetings to accommodate a resident’s representative (such as conducting the meeting in-person, via a conference call, or video conferencing), and planning enough time for information exchange and decision making.

• 483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans  §483.21(a)(1) 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. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable.
• 483.21(a)(3) 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.

The format and location of the summary is at the facility’s discretion, however, the medical record must contain evidence that the summary was given to the resident and resident representative, if applicable.  The facility may choose to provide a copy of the baseline care plan itself as the summary, as long as it meets all of the requirements of the summary.

The facility must provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation.  Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing.

LeadingAge Ohio encourages facilities to utilize the LTC survey pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the March 9 call at 10:00am.

As Ohio annual surveys continue, LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.