In Part 1, we said that “we have a care plan” isn’t the same as “we’re compliant.” In Part 2, we looked at what that gap looks like in real citations. Now for the question we’d be asking if we were sitting in your seat: so what do we do about it? Part 3 is about finding these problems on your schedule instead of a surveyor’s.
Something stood out as we read through those citations. When the surveyor asked staff about a missing care plan, the answer was almost never “we didn’t know we needed one.” It sounded more like this:
- “she must have forgotten to initiate it”
- “it must have been overlooked”
- “had overlooked the antibiotic, and a care plan had not been initiated”
- “unable to explain how the care plan to address the use of the anticoagulant was missed”
Everyone knew the care plan should exist. What broke was the hand-off. Despite what processes the facilities may have thought they had in place, nobody was clearly responsible for noticing the new order, the new diagnosis or the new device and getting it onto the plan. That’s a process problem, and process problems can be fixed. Here’s where we’d start, pattern by pattern.
Pattern 1: Start with your own Matrix
The care plans that go missing most often belong to things that already show up on your Matrix. Use that. Pull the list of residents on anticoagulants, oxygen, catheters, dialysis, hospice, antibiotics, and psychotropic medications, plus anyone with a PTSD diagnosis. Open every plan. Is it there? Does it say something about this resident – what to monitor and who’s responsible – or is it just a heading? An hour of this will tell you whether Pattern 1 lives in your building . . . if you can manage to get through an hour not frustrated.
Then look at what happened after a hospital stay. In one citation, an activities care plan was discontinued when the resident went to the hospital and “was not reactivated” when the resident came back. Readmission is a good time to ask what got closed out and never reopened. Review the plan of care to ensure the resident’s current needs are addressed in the plan of care.
Build a trigger list and give it an owner
Decide ahead of time which events automatically send someone back to the care plan:
- new order for a high-risk medication or device
- new diagnosis
- return from the hospital
- hospice election
- a fall
- new behavior
- new refusal
Then decide who owns each one. Your morning report is a natural place to do it. For every new order, ask one question out loud: “Where is this on the care plan?” (Review and revision timing sits under a neighboring tag, F657, but you don’t have to wait for a survey to start asking.)
Patterns 2 and 3: Read it the way an aide would
Pick five care plans, then pull the care card/task list the aides use for those same residents. Read the card without the chart in front of you, as if you were a CNA hearing about this resident for the first time. Could you tell what to do? Then go back to the care plan and see whether the card says the same thing. Two quick tests help:
- Look for leftovers. Unfilled template prompts like “(specify diet type)”, a focus that ends at “related to”, or “may” in front of interventions for a resident who can’t do them without staff. If your EMR lets you search care plan text, search for them.
- Test every goal. At the next review, could two different nurses look at the goal and agree on whether it was met? “Resident will be safe” fails. “Mr. T will walk to the dining room for meals with his walker and one staff member at least five days a week by his next quarterly review” passes.
Pattern 4: Ask, then write it down
When a resident refuses something, the plan should show what staff will offer, how they’ll approach it and what alternatives the resident was offered. And when the refusals stop, resolve the stale behavior care plan. Neither is much work, and both are things surveyors notice. Another way to ensure you’re addressing resident needs is to ask this question every care plan meeting: “What’s one thing about your day you’d change?” Preferences you never asked about can’t make it into the plan. Save both your residents and team the frustration.
For each resident you review, pick one hands-on intervention – a device, a positioning schedule, supervision at meals – and check three places: the care plan, the CNA assignment/task list, and the resident. If it’s in the first and not the second, you’ve found the Geri-sleeves problem from Part 2. If it’s in both and not at the bedside, you’ve found the other one. Then ask the aide:
- What do you need to know to care for this resident – and where do you look?
- Is there anything special you do for them – a device, a position, help at meals?
- What would you do if they refused?
- Who do you tell if something changes?
“I just do what the last shift did” is an answer worth taking the time to find out about now.
Keep score and close the loop
Write down what you find: which pattern, which unit, which shift, which discipline. Fix the plan, and fix the hand-off that let it happen. If you don’t fix the broken process, you’ll run into the same issues again and again. Take the trends to QAPI. A handful of residents reviewed every week, from different units, will tell you more than one big audit annually.
If you only do one thing this week, pick a high-risk area and review the plan of care for every resident who has that problem, medication or diagnosis. Back in Part 1, we asked whether the care plan sounds like the resident and whether the staff caring for them would know what to do if you asked. Now you have a way to find out – before a surveyor asks for your staff.
Want a second set of eyes? CMSCG reviews care plans, task lists and the bedside as part of mock surveys and record reviews. Call 631.692.4422 or email info@cmscg.net.
