In Part 1 of our Ftag of the Week for F656, we reviewed the regulatory requirements for developing and implementing comprehensive care plans. We reviewed some examples of specific vs. non-specific goals, and in this post, we’ll review some more care planning considerations (and requirements).
Assessment and Care Planning Considerations
Per the Interpretive Guidance (IG) in SOM Appendix PP, staff are expected to use the MDS, as a minimum, to assess the resident’s clinical condition, cognitive status, functional status and services used to develop the CCP.
Do We Need to Care Plan for That?
If a Care Area Assessment (CAA) is triggered, then staff need to further assess the resident to determine if the resident is at risk of developing or currently has a weakness/need associated with that CAA and identify how the risk/weakness/need affects the resident. The rationale for care planning for a triggered CAA needs to be documented in the resident record.
It’s also important to not forget about risks/weaknesses/needs which are identified by the MDS, but don’t cause a CAA to trigger. Staff are still responsible for addressing these areas of concern and determining if a care plan needs to be developed and implemented to address them. Remember, a surveyor will expect the facility to address any identified risk – even if it doesn’t trigger a CAA.
Here’s a couple examples that may require further review:
- Mild pain which is reported less than daily – this won’t trigger a CAA, but it doesn’t mean the resident’s pain doesn’t need intervention.
- Low mood indicators, such as a PHQ-9 score of 3 – this won’t trigger the Mood CAA, but still warrants further support
- New refusal of showers – since it’s one type of care, it won’t trigger the Behavioral CAA, but this requires person-centered care planning and interventions. Remember, getting back to the idea of being person-centered, the resident’s preference may be something as simple as a preference to shower in the morning vs. the evening, but we haven’t identified that and need to adjust to the resident’s preference vs. unit scheduling.
What about the Resident’s Right to Refuse?
Refusals are addressed in the IG. The regulatory expectation is that the CCP:
- identifies the care or service which is being declined
- identifies the risk which the refusal poses to the resident
- addresses efforts by the IDT to educate the resident/ representative
- includes alternatives to address the need/risk which the facility has taken
Addressing Cultural and Trauma-Informed Needs
Cultural Competency
Interventions in the resident’s care plan are expected to reflect the resident’s cultural needs and preferences and align with the resident’s cultural identity. Staff are expected to be culturally competent – which means the facility should be ensuring that the staff receives appropriate training. Some concerns which may need to be addressed with resident-specific interventions include:
- Religious/spiritual observances
- Communication style/language
- End of Life cultural practices
- Cultural activities preferences
- Dietary restrictions which are tied to a resident’s culture or faith
Don’t Forget About Trauma-Informed Care
As part of the revisions to the Requirements of Participation (RoPs), the need for care to be trauma-informed became a requirement. Identifying and addressing past trauma is an area that often needs more effort. Providers are required to recognize the effect that past trauma may have on a resident and collaborate with members of the IDT, including the resident/ representative, to identify and implement individualized interventions.
Facilities should ensure that the following processes are being followed:
- Identifying trauma-triggers and stressors – Ensure the care plan reflects known trauma history, observed triggers that escalate distress, and environmental or interpersonal factors that worsen symptoms. Way too many providers miss the boat here, which could result in negative outcomes for the resident and/or behavioral responses to triggers/stimuli.
- Ensuring emotional and physical safety – Interventions should identify how staff can create a sense of safety for a resident. This is where the care plan template library often creates issues. For instance, if the resident has a past history of trauma and prefers same-sex only caregivers, then the team shouldn’t be adding generic, unrelated interventions just for the sake of adding them.
- Supporting choice, control and autonomy – There’s so much to be said for ensuring that residents have a sense of control in their lives. Sometimes it’s as simple as offering choices during care, allowing the resident to set the pace of an activity, or respecting refusals and collaborating to explore alternatives. Sometimes it’s more complex and requires some thought . . . but the time spent trying to come up with an individualized plan may be significantly less than the time your staff spend trying to “manage” a resident’s behaviors which they are inadvertently triggering.
- Planning based on strengths vs. deficits – Identify the resident’s personal strengths, coping mechanisms already in use, supportive relationships and the like when developing the CCP.
- Avoiding re-traumatization – This is another area of concern. Staff need to understand what could be potentially triggering to a resident to avoid the risk of re-traumatization and a negative outcome. Some residents may not do well with multiple caregivers in the room – resulting in refusals but also consider the potential for a negative psychosocial outcome. Other residents may not handle sudden changes to their routine well. Consider that some “behaviors” may actually be fear-based, mimic past trauma and may result in refusals/resistance.
Remind your staff – care planning is more than just writing something down. It’s a deliberate, resident‑driven process that requires the IDT to understand who the resident is, what matters to them, and how their needs can be met in a way that supports safety, dignity, and quality of life. F656 isn’t about filling in boxes and saying you’ll look again in 90 days — it’s about creating a meaningful plan that guides care, reflects the resident’s voice, and can be implemented consistently across all shifts. When your team approaches care planning with this mindset, the care plan becomes a living document that truly supports person‑centered care . . . and stands up to surveyor scrutiny.
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