ABCs of Care Planning

The ABCs of Care Planning
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare International, Inc.
(HHI)
Presented by:
Beckie Dow, RN, RAC-MT
Director of MDS/Nursing Program Development

Speaker Bio
Over 20 Years Experience in Long-term
Care
Clinical and Reimbursement Accuracy
in Assessments
Quality Assurance Activities
Interrelation between MDS, Care
Planning, QA and Clinical Excellence at
the Bedside
AANAC Master Trainer
Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2

Today’s Objectives
Define the purpose of the Care Plan
Define the purpose of the discharge
Care Plan and summary
Identify the correlation between the
MDS, CAAs, accurate RUG-IV
classification, and the Care Plan
List three components of a resident-
centered Care Plan

OIG Report February 2013
Used 2009 stay data
Sample of 190 stays that projects to
1,104,692 stays in the population
For each stay the OIG determined if
care plans contained measureable
objectives and detailed time frames for
the following eight categories of service
(see next slide)

OIG Report February 2013
Scheduled toileting plans or bladder
retraining programs
Parenteral IV or feeding tubes
Skin treatments
Speech, occupational, and physical
therapy
Respiratory therapy
Restorative nursing services

OIG Report Findings
The OIG found that:
74% of NHs surveyed in 2007 had at least
one deficiency related to quality of care
SNFs often did not develop appropriate
psychosocial services Care Plans or
provide all services identified in Care Plans
SNFs failed to meet one or more Medicare
requirements for beneficiary assessments
or Care Plans about atypical antipsychotics

OIG Report Findings
The OIG found that:
There were quality-of-care problems with
beneficiaries discharged between SNFs and
other facilities
There were quality-of-care problems
within the SNFs, including development of
pressure ulcers, malnutrition, dehydration,
side effects from not receiving medications,
and inadequate staffing levels leading to
poor patient outcomes

OIG Report
Recommendations to CMS
Strengthen the regulations on Care
Planning and Discharge Planning
Provide guidance to SNFs about Care
Planning and Discharge Planning
Increase surveyor efforts to identify
SNFs that do not meet Care Planning
and Discharge Planning requirements
and hold these SNFs accountable

OIG Report
Recommendations to CMS
Link payments to meeting quality-of-
care requirements
Follow up on SNFs who failed to meet
Care Planning or Discharge Planning
requirements or who provided poor
quality care

Medicare Requirements
Related to Quality of Care
Develop a Care Plan for each beneficiary
and provide services in accordance with
the Care Plan
Provide services to attain or maintain the
highest practicable physical, mental, and
psychosocial well being of each
beneficiary in accordance with the Care
Plan
Plan for each beneficiary’s discharge to
ensure safe transition to next care settings

Steps of the Nursing Process
1. Assess
2. Diagnose
3. Outcomes / Planning
4. Implementation
5. Evaluation

Developing the Care Plan
The resident Care Plan should be based
on:
Resident’s strengths
Resident’s weaknesses
Health issues and conditions
Residents unique characteristics,
strengths, and needs

Developing the Care Plan
The Care Plan must:
Be based on a thorough resident
assessment
Evidence effective clinical decision making
Be compatible with current accepted
standards of practice
Will provide a strong basis for optimal
approaches to quality of care and quality of
life needs of the resident

Care Plan to
Support Level of Services
Care Plan shows how we plan to provide
services to the patient
Lack of medical record documentation for
RUG-IV items on the MDS may create the
appearance of fraud
Care Planning from our Care Area Trigger
(CAT) items will show that we are meeting
the clinical needs of our patient in
accordance with the plan of care

Harmony Healthcare International, Inc. 15
Goal of the RAI process
The delivery of care to meet the needs
of a resident is based upon the
completion of a comprehensive
assessment and the development of a
Care Plan based upon the MDS
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RAI Process
The facility must develop a care plan
that meets these guidelines:
Individualized
Comprehensive
Measureable goals
Timetable to meet the goals
KEY POINT: The Goal of the RAI
Process is the Care Plan

Resident Participation in the Care
Plan
The resident has the right to participate
in care planning and treatment or
changes in care and treatment
The facility should encourage and assist
the resident to participate in choosing
care and treatment options
F-280 Care Plan (broad tag)

Plan
F-280:
“The resident has the right to, unless
adjudicated incompetent or otherwise
found incapacitated under the laws of
the State, participate in planning care
and treatment or changes in care and
treatment”

Plan
Surveyors are instructed to look for
evidence that the resident was afforded
the right to participate in care planning
or was consulted about care and
treatment changes
Surveyors will ask the resident or their
representative during survey
Includes attending care plan
conferences, if the patient desires

Plan
The resident has the right to refuse
treatment and to select among
treatment options before the care plan is
instituted
Facility staff must make the process
easy to understand for the resident or
family
Residents questions and concerns must
be addressed by the facility

CAA Process
When implemented properly, the CAA
process should help staff:
Develop, to the extent possible,
interventions to help improve, stabilize or
prevent decline in physical, functional, and
psychosocial well-being, in the context of
the resident’s condition, choices, and
preferences for interventions

CAA Process
When implemented properly, the CAA
process should help staff:
Address the need and desire for other
important considerations, such as
advanced Care Planning and palliative
care; e.g., symptom relief and pain
management

Harmony Healthcare International, Inc. 23
Care Area Assessments
1. Delirium
2. Cognitive Loss/Dementia
3. Visual Function
4. Communication
5. Activity of Daily Living (ADL)
Functional/Rehabilitation
Potential
6. Urinary Incontinence and
Indwelling Catheter
7. Psychosocial Well-Being
8. Mood State
9. Behavioral Symptoms
10. Activities
11. Falls
12. Nutritional Status
13. Feeding Tubes
14. Dehydration/Fluid
Maintenance
15. Dental Care
16. Pressure Ulcer
17. Psychotropic
Medication Use
18. Physical Restraints
19. Pain (NEW)
20. Return to
Community Referral
(NEW)
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Discharge Planning
When the SNF anticipates the discharge
of a beneficiary to another care setting
or home it must plan for the discharge
As part of this planning the SNF must
develop a discharge summary to help
ensure coordination of care and safe
transition to the new setting

Discharge Planning
The discharge summary should include:
A summary of the beneficiary’s stay
A summary of the beneficiary’s status at
the time of discharge
A post-discharge Plan of Care, including:
Beneficiary’s and family’s preferences
How the beneficiary will access services
How care will be coordinated among
caregivers
Discharge education and instructions

Discharge Planning
The discharge summary should provide
an adequate clinical picture of the
beneficiary and detailed individualized
care instructions to ensure that care is
coordinated and that the beneficiary
transitions safely from one care setting
to another
The interdisciplinary team, including
the physician, should participate

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
Bdow@harmony-healthcare.com
www.harmony-healthcare.com
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Effective Care Planning
August 21, 2013
10:00-11:00

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ABCs of Care Planning

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