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    The care plan creates an organized approach to meeting the resident’s needs.  A.A. Milne defined organized by saying, “Organizing is what you do before you do something, so that when you do it, it’s not all mixed up.”  The purpose of care planning is to keep health care from being all mixed up.

    A clinical staff who is working without a plan can easily get care processes mixed up and neglect important issues critical to successful care of the physical, mental, and emotional health of the resident.  Effective resident care depends on asking and answering the questions: “What are the health care concerns and what should we do about them?”  The resulting care plans get things organized and tell staff what they should do and how they should do it.  Assessment and planning are essential parts of any successful health care process.


  ∆  Care plans - a complicated process.
    Comprehensive care planning includes all disciplines that involve or support the treatment of a resident.  The interdisciplinary care team developing the plan should include the attending physician, the registered nurse responsible for the resident, certified nursing assistants involved in direct care processes, and representatives of the other departments providing supportive services such as dietary and activities.  Participation by the resident, if they are able, and family members or the legal representative of the resident can participate, adding important personal information to the process.

   Although a structured process is followed in developing the plan, each plan should be different, reflecting the individual needs and personality of the resident.

    Examples of what will be presented at the care plan meeting can be found in the two care plans listed below.  As can be seen in the examples, each is presented differently because there is no prescribed format, only required types of information in a care plan.

    The first is from a nursing home in England and represents a basic problem, goal, and response planning process.   To see the full care plan at the site, click on Open all under the line Care Plan for Mrs Jane Smith.  The second covers a single sensory-perception problem in more detail.


  ∆  Care plan objectives.
    The primary objectives of nursing home care are to reach and/or maintain the highest level of physical and mental functioning possible for each resident under their individual medical constraints.  The following regulation is the overall goal of the care plan.  Each resident’s plan of care should reflect those objectives.

    Quality of Care - Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

    Highest practicable physical, mental, and psychosocial well-being is defined as the highest possible level of functioning and well-being, limited by the individual’s recognized pathology and normal aging process. The highest practicable level is determined through the comprehensive resident assessment and by recognizing and thoroughly addressing the physical, mental, and psychosocial needs of the individual from a plan of care.

   The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment and within the constraints of recognized pathology and the normal aging process.

 ∆  Comprehensive care plans.
    To fully address the care needs of a resident, the nursing  home must call on all professional staff who may provide clinical and other supportive care to contribute to assessing care requirements.  The participation of a wide range of disciplines, the resident, and family members attempts to take all aspects of the residents life before admission and their present physical and psychosocial condition into consideration to address the complete person’s care needs in a residential health care facility.

    The plan must meet the goals of the rules of §483.25 Quality of Care; be consistent with the resident’s specific conditions, risks, needs, behaviors, preferences; and meet current standards of practice with measurable objectives and timetables for specific interventions.

    The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:

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 part §483.25 Quality of Care ; and

Any services that would otherwise be required under Quality of Care, but are not provided due to the resident’s exercise of rights under Resident Rights, including the right to refuse treatment ...

    These requirements reflect the facility’s responsibility to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. However, in some cases, a resident may wish to refuse certain services or treatments that professional staff believe may be indicated to assist the resident in reaching his or her highest practicable level of well-being. Desires of the resident should be respected and documented in the clinical record.

  ∆  Assessment - the care plan foundation.
    For the facility to develop a well-founded plan of care, they must establish the resident’s condition and needs using a reliable method that is uniform from resident to resident.  Such an assessment would be designed to put them on the path to attaining and/or maintaining the resident’s highest mental and physical functions.

   A facility must ... use the results of the assessment to develop, review and revise the resident’s comprehensive plan of care.

    The nursing home care delivery system is a complex undertaking guided by professional standards of practice and regulatory requirements.  The approach necessary to fulfill those requirements is a structured assessment process that collects specific information required by Medicare and Medicaid based on the findings from applying the Minimum Data Set (MDS).  The MDS is a preliminary screening tool to identify areas needing a comprehensive assessment.

   The process of completing the assessment form does not constitute the entire assessment that may be needed to address issues and manage the care of individual residents. The form may not trigger every relevant issue or concern for an individual resident and not everything that the assessment form triggers is necessarily clinically significant or requires an intervention.

 ∆ Planning for discharge.
    Whether a resident is discharged to their home, a lower level of care, or an acute care setting, there must be a communication to the resident, family, and next care givers of the history, assessments, and care provided to supply knowledge necessary to support the continued care needs in the new setting. 
    Discharge Summary - When the facility anticipates discharge a resident must have a discharge summary that includes:
  A recapitulation of the resident’s stay;

 A final summary of the resident’s status to include items in a comprehensive assessment, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and

A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

    Anticipates means that the discharge was not an emergency discharge such as hospitalization for an acute condition or due to the resident’s death.

    Adjust to his or her living environment means that the post-discharge plan, as appropriate, should describe the resident’s and family’s preferences for care, how the resident and family will access these services, and how care should be coordinated if continuing treatment involves multiple caregivers. It should identify specific resident needs after discharge such as personal care, sterile dressings, and physical therapy, as well as describe resident/caregiver education needs and ability to meet care needs after discharge.

    Post-discharge plan of care means the discharge planning process, which includes assessing continuing care needs and developing a plan designed to ensure the individual’s needs, will be met after discharge from the facility into the community.

    A post-discharge plan of care for an anticipated discharge applies to a resident whom the facility discharges to a private residence, to another nursing facility or skilled nursing facility, or to another type of residential facility such as a board and care home or an intermediate care facility for individuals with mental retardation.

 ∆ Interdisciplinary team planning. 
    The regulation requires that:  A comprehensive care plan must be--
   Developed within 7 days after the completion of the comprehensive assessment;

  Prepared by an interdisciplinary team, that includes the attending physician, a 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, the resident’s family or the resident’s legal representative; and

(iii)  Periodically reviewed and revised by a team of qualified persons after each assessment.

    As used in this requirement, Interdisciplinary means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team meets its responsibilities in developing an interdisciplinary care plan is at the discretion of the facility.

    The physician must participate as part of the interdisciplinary team, and may arrange with the facility for alternative methods, other than attendance at care planning conferences, of providing his/her input, such as one-on-one discussions and conference calls.

  ∆  Physician’s admission orders.
    Because the plan of care is complicated and takes some time to develop,  the staff needs direction to the care of the new resident in the meantime. Orders from the admitting physician serve that purpose while assessments are made by staff to establish a comprehensive care plan based on actual experience with the new patient.

    The regulation requires that:  At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care.

    Physician orders for immediate care are those written orders facility staff need  to provide essential care to the resident, consistent with the resident’s mental and physical status upon admission. These orders should, at a minimum, include diet, necessary drugs, and routine care to maintain or improve the resident’s functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan.  Physician’s orders act as the new resident’s temporary care plan.This requirement also applies to a resident returning from a hospital stay where a significant change of condition may have been found or treated.

  ∆  Family and resident participation care planning.
  The resident has the right to, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.

    A resident whose ability to make decisions about care and treatment is impaired, or a resident who has been formally declared incompetent by a court should, to the extent practicable, be kept informed and be consulted on personal preferences that may be reflected in the care plan.

   The resident has the right to refuse specific treatments and to select among treatment options before the care plan is instituted.   The right to participate in planning care and treatment means that the resident is afforded the opportunity to select from alternative treatments. This applies both to initial decisions about care and treatment and to decisions about changes in care and treatment.

    - While Federal regulations affirm the resident’s right to participate in care planning and to refuse treatment, the regulations do not create the right for a resident, legal surrogate or representative to demand that the facility use specific medical intervention or treatment that the facility deems inappropriate.  Statutory requirements hold the facility ultimately accountable for the resident’s care and safety, including clinical decisions. -

    Whenever there appears to be a conflict between a resident’s right and the resident’s health or safety, the facility must attempted to accommodate both the exercise of the resident’s rights and the resident’s health, including exploration of care alternatives through a thorough care planning process in which the resident may participate.

    Family members and others with a close relationship with the nursing home resident are urged to participate in the care planning process when invited.  Although the resident and family should, to the extent practicable, participate in development of a care plan, the care plan schedule must be followed with or without their involvement but their input can be reflected in a revised care plan at any time.  The care plan is flexible and other than meeting the specific schedule of assessments, it can be updated when there has been a change of condition or at the request of the resident, family member or other appropriate person.

The facility has a responsibility to assist residents to participate, such as helping residents, family members, and legal surrogates or representatives understand the assessment and care planning process; when feasible, holding care planning meetings at the time of day when a resident is functioning best; planning enough time for information exchange and decision making; and encouraging a resident’s advocate, family member, or friend to attend, if desired by a resident.

  ∆  Professional standards and accepted practices.
    The essence of quality of care come from three sources. The first is clear identification of the components of the care goals to be attained.  The second is the competence of those providing care, and third is their use of acknowledged best practices in delivering that care.

    The regulation requires that:  The services provided or arranged by the facility must-
    (i)    Meet professional standards of quality and;
    (ii)   Be provided by qualified persons in accordance with each resident’s written plan of care.

    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 such as:
    * Current manuals or textbooks on nursing, social work, physical therapy, etc.
    * Clinical practice guidelines published by the Agency of Health Care Policy and Research.
    * Current professional journal articles.
    * Standards published by professional organizations such as the American Dietetic Association,    
       American Medical Association, American Medical Directors Association, American Nurses
       Association, National Association of Activity Professionals, National Association of Social Work,
        and so forth.

  ∆  Access to resident’s care plan.
    The care plan is part of the resident’s medical record.  As such it is subject to the same restrictions and is not opened to anyone who requests to review the document.  The resident has the right to limit access by others to both the plan and the care plan review meeting.

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