Person-Centered Care and Care Planning Makes it into the New CMS Regulations, Part II

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Carmen Bowman Headshot

Carmen Bowman,  Author, Consultant, Edu-Catering: Catering Education for Compliance and Culture Change

The new CMS regulations which went into effect Nov. 26, 2016 now include many culture change practices and principles, one of which is person-centered care planning. In last week’s  article, we had to start with Resident Rights (483.10) as it now requires nursing homes to protect and promote the rights of the resident; the resident’s wishes and preferences must be considered in the exercise of rights by the representative, risks and benefits of proposed care, as well as alternatives or treatment options must be shared with the resident and many new, strong specifics regarding the nursing home honoring the resident’s right to plan their own care and develop their own care plan.

We now turn our attention to the new section Comprehensive person-centered care planning (483.21) and what it requires.

New is a requirement for a baseline care plan within 48 hours of move in and a summary given to resident and/or representative. Details are in the regulation but they are probably what you do already. Many states have requirements for a care plan within 24 hours so it is likely this is not a big change for most homes.

The care plan is to include the resident’s goals for admission and desired outcomes. This is so important, the resident’s goals, resident’s desired outcomes, not anyone else’s. If you are not yet asking residents their goals, now is your time to discover the benefits of it. It is their life. They are their goals. In some cases, it helps the resident to take back ownership of their life which is a very good thing. Even if dementia is involved, challenge your team to really listen to the person in whatever way they communicate. They tell us things they like and don’t like in so many ways that don’t always include words. If someone punches you when you wake them up, guess what they just told you?

Although homes have been implementing PASARR recommendations all along, it was not a part of regulatory text which now requires the care plan to include: Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations.

The resident’s preference and potential for future discharge and discharge plans in the comprehensive care plan, as appropriate. Hopefully this is nothing new and you have been including discharge planning as part of the care plan as many homes have. The best part — address the resident’s goals.

Regarding care conference, CMS addsto the interdisciplinary team (IDT),
  • a registered nurse with responsibility for the resident,
  • a nurse aide with responsibility for the resident,
  • a member of food/nutrition services staff.

CMS commented in its Executive Summary of the Final Rule, “We do not require that any of the members of the IDT participate in person. Facilities have the flexibility to determine how to hold IDT meetings whether in person or by conference call, i.e. email or written notes.”

Direct care givers attending care conference has been identified as a best practice, including in the Artifacts of Culture Change measurement tool that CMS funded. Thus, if it is new to you, you might consider a progression having CNAs attend for 5 minutes but keeping as a goal to have them participate in the whole conference. Homes that start with only the 5 minutes soon realize so many other topics come up for which the direct care giver is needed. It is much more helpful to have the right people able to explain things to the resident and family rather than the typical institutional response: “We’ll have to check into that and get back to you.”

A continued requirement by CMS is: To the extent practicable, the participation of the resident and the resident’s representative(s).

However, a new addition is: An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan.

Also new is: Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. Do you ask residents if there is any team member the resident desires present in his/her care conference? Residents may have a close relationship with a certain team member that does not usually attend care conferences. At the very least, giving the resident the option to think about it is the next level of decision making given back to the resident.

As discussed in the last article, CMS has identified the resident right to identify individuals or roles to be included in the planning process. Maybe the resident doesn’t want a certain family member there. So, the next question becomes, do you ask residents if they want the family there. Sometimes we don’t ask, we assume. It simply puts all control back in the lap of the person the way it should be.

Something very new that CMS now requires is that care plans must be culturally-competent and trauma-informed. This will take another article another time.

I left the best for last. Thankfully and not surprisingly CMS continues the good requirement for nursing homes to include on the care plan: The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.

Do you, do we, really care plan the services we will provide to help each resident in their unique position to attain or maintain their highest practicable level in each area? Do you care plan the individual’s highest practicable level of physical well-being? A hard question might be are residents really given enough time to do for themselves what they can physically?

Do you care plan each individual’s highest practicable level of mental well-being? Honestly, I’ve never seen this done.  The closest we get is identifying cognitive impairment but not identifying what the person’s highest level possible is.

Do you care plan highest practicable level of psychosocial well-being? Haven’t ever seen this either. It encompasses so much more than group activities and identifying depression.

Consider adding these as separate sections to care plans as it will force you to think and talk about what this person’s highest practicable level really is. Then you can plan the services to be provided to help attain or maintain it as required. Don’t forget this applies to every single person. Don’t get trapped into thinking only about people at a high functioning level. During a survey many years ago, Nora was cleaning and dusting with her hand. Her highest practicable level of well-being (all three areas represented here perhaps) was to clean with the housekeeper every day in the morning. Now it could be real, not just a cloth but one with Endust on it, providing oversight while honoring her contribution to the community. Challenge yourself to do this for each resident, you’ll be glad you did. Plus, it continues to be required.

3 comments on “Person-Centered Care and Care Planning Makes it into the New CMS Regulations, Part II

  1. joan cullinane on

    I turned to this page because I was so taken aback by the care plans at work. You have made me feel that there are people out there who don’t look up what to say in a book or call something and “I” plan because they affixed an “I” to what they saw in a book. Also agree that what we do in long term care would not pass snuff in mental health care treatment plans.

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