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

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


The new CMS regulations which went into effect Nov. 26, 2017 now include many culture change practices and principles. It is exciting when the government adopts what we know as best practice. They didn’t get them all in there but many. (It will be a grand day when the government actually calls them homes or communities instead of a facility — who wants to live or even stay in a facility?)

CMS starts by defining person-centered care stating it means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives (Definitions 483.5).

This is a big win. Notice that although leaders in culture change have moved on to language such as person-directed care/living and person directed culture, CMS’ definition actually includes all that.

In this Part I, we must cover Resident Rights (483.10). Why? Take a look at how strong supporting residents’ rights has become: The facility must protect and promote the rights of the resident and the resident’s wishes and preferences must be considered in the exercise of rights by the representative. Unfortunately, we often give families too much power too soon. Instead of ever asking a family member what they want, we need to be asking what their relative/the resident wants, what that person has said about that issue, how they have lived their life around that issue, etc. I call it reframing the question always to the resident’s wishes and now the regulation guides us to do just that.

We also start with Resident Rights since it has so much to say regarding care planning. Residents continue to have the right they always have had to participate and develop their own care plan. However, CMS has added many more specific practices around this now: including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. All of that is new. Residents requesting who they want at their care conference, requesting additional meetings potentially and revisions to their care plan. Now we’re talking.

That’s not all, they also have the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. Wow. This puts the person in charge as it should be. If you’re not asking residents their goals for their care and life, do it. It’s their life, their goals, their diabetes, etc. and it takes the onus off of the home, the team. Anyone else tired of writing goals for someone else? Would you write goals for me or me for you? It’s not normal. And remember, a goal is a goal. Anyone have goals they haven’t met yet? Me too.

As well, the resident has the right to be informed, in advance, of changes to the plan of care.

To go with this, the right to see the care plan, including the right to sign after significant changes to the plan of care. This implies they should be seeing the changes to the plan whenever there are any.

Regarding the care planning process, homes now must include assessment of resident’s strengths and needs. This is good but don’t forget you can go way beyond what is required. “Don’t let the MDS box you in” is how I think of it. Find out resident passions, and what brings meaning and purpose to their life; their daily pleasures, their simple pleasures. Find out what matters most. Personally I think we should be care planning sleep, getting outdoors, movement/mobility and individualized engagement. These things matter, are part of health and rarely get any attention.

Now homes are to incorporate the resident’s personal and cultural preferences in developing goals of care. This is the best part. Finally, CMS leads us to find out and incorporate the resident’s goals. Don’t despair if one can’t tell you, they may have already in advanced directives, living wills, The Five Wishes document, in what they have told family, and in what they have told you. People “tell” their preferences in many ways other than words. If someone spits out their green beans, what did they just tell you?

The home is to honor the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. Don’t you love how it is all given back to the person? The resident is back in the driver’s seat of their lives.

CMS deserves kudos for now requiring homes to be sure to honor the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This is fantastic and very reflective of the principles of culture change, of a person directed culture.

CMS deserves kudos for this even stronger requirement for homes to also honor: The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Residents tell us their preferences and what their choices are all the time. The question becomes, are we listening? Another example is when a person throws their positioning alarm across the room, what did they just tell us? Do we listen and better yet, do we honor the choice they just told us?  Do we even ask residents if they want that noisy, startling alarm? Not usually because if we did, we would never have used them. I admire some homes dedicated to person-directed living who are actually asking residents if they want the alarms and discontinuing them when they say no.

Asking residents more questions about wanting this or that, from big things to little, is the key.


Stay tuned for PART II when we take a closer look at the new section called Comprehensive resident-centered care plans (483.21)