“Our care plans are all in the EMR, so we’re covered.” We have all heard some version of this often, and it’s easy to understand why. Having a care plan library in your EMR is a good starting point when developing an individual resident’s care plan But, as you’ll see, F656 doesn’t ask whether a document exists. It asks whether there was a plan developed that addresses the individual resident’s goals, preferences and needs – and whether it’s actually being carried out.
This week, we’re starting a multi-part “Ftag of the Week” series on F656 Develop/Implement Comprehensive Care Plan, because it’s an area where many staff could use a refresher. In Part 1, we’ll cover what the tag requires and why “we have a care plan” doesn’t mean the same thing as “we’re compliant.”
F656 – What’s Required
Appendix PP of the State Operations Manual (SOM) requires that for each resident, the facility develops and implements a comprehensive, person-centered care plan that’s consistent with resident rights and includes measurable objectives and timeframes. It must meet the resident’s needs that have been identified in the comprehensive assessment – everything from medical to nursing to mental and psychosocial needs.
The comprehensive care plan must address the services that will be provided by the facility, including the need for any specialized services or specialized rehab services which come about as a result of PASRR recommendations. It needs to address the resident’s goals for admission and desired outcomes, the resident’s preference (and potential for) future discharge, and discharge plans. Services provided must be culturally-competent and trauma-informed.
Key Definitions
Per Appendix PP:
“Person-centered care” refers to care where the resident is the locus of control and ensures that the resident is supported in making his/her own choices and having control over their daily lives.
This is one of the basic tenets of nursing home care, but it’s an area that we tend to see staff struggle with. It’s easy to just click off a care plan template, schedule showers on the shifts that we have selected for the unit’s convenience and forget about addressing the resident’s preferences, choices and goals. It’s also disheartening to look at a facility’s EMR and see the same cookie-cutter care plan for most residents – irrespective of their unique needs. The Interpretive Guidance in Appendix PP states that staff should make an effort to understand what each resident is communicating to identify what’s important with regard to daily routines, preferred activities and understanding what the resident’s life was like before arriving at the facility. Taking the time to do this helps to develop an informed person-centered plan versus what’s in a template.
“Goal” refers to the resident’s desired outcomes and preferences for admission which are used to guide decision-making during the care planning process.
Other goal-related definitions to be aware of:
- “Measurable” refers to the ability to be evaluated or quantified
- “Objective” refers to the statement which describes the results that will be achieved to meet the resident’s goals
“Intervention” refers to an action/ treatment/ activity/ procedure which is implemented to help meet an objective.
Interventions must be included in the care plan to enable the resident to meet his or her goals. Per the IG, interventions are the specific care and services that will be implemented. Is that what’s happening with your care plans?
So far, we’ve covered the “develop” part of F656. The “implement” half is where facilities often get into trouble. A care plan can be well-written and still not be followed by staff. If the aide providing care doesn’t know what’s in the plan, or the interventions on paper aren’t what’s actually happening, surveyors will notice. Next up, we’ll continue reviewing what you need to know about this requirement and review some actual survey citations. We’ll get practical, with ways to catch these problems before a surveyor does. Until then, pick up a few care plans and ask yourself – does this sound like the resident? Would staff caring for this resident know what to do if I asked them?
