Car e Planning: T HE R E SIDE NT S VOICE Sande r s - - PDF document

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Car e Planning:

T HE R E SIDE NT ’S VOICE

Sande r s Consulting Kathy Sande r s R N, R AC-CT , C-NE

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T he Ca re Pla nning : T he Re side nt’ s Vo ic e wa s de ve lo pe d a s a n e duc a tio na l pro g ra m a nd re fe re nc e fo r lo ng -te rm c a re sta ff. T

• the b e st o f o ur kno wle dg e ,

it re fle c ts c urre nt fe de ra l re g ula tio ns a nd pra c tic e s. Ho we ve r, it c a nno t b e c o nside re d a b so lute a nd unive rsa l. T he info rma tio n c o nta ine d in this wo rksho p must b e c o nside re d in lig ht

• f

the individua l

• rg a niza tio n a nd sta te re g ula tio ns. T

he a utho rs disc la im re spo nsib ility fo r a ny a dve rse e ffe c t re sulting dire c tly o r indire c tly fro m the use o f the wo rksho p ma te ria l, fro m a ny unde te c te d e rro rs, a nd fro m the use r’ s misunde rsta nding o f the ma te ria l.

Disc la ime r

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T he a utho rs put fo rth e ve ry e ffo rt to e nsure tha t the c o nte nt, inc luding a ny po lic ie s, re c o mme nda tio ns, a nd sa mple do c ume nts use d in this tra ining , we re in a g re e me nt with c urre nt fe de ra l re g ula tio ns, re c o mme nda tio ns, a nd pra c tic e s a t the time

• f

pub lic a tio n. T he info rma tio n pro vide d in this tra ining is sub je c t to re visio n b a se d o n future upda te s a nd c la rific a tio ns b y CMS.

Disc la ime r Co ntinue d

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T he le a rne r will b e a b le to :

• De sc rib e the re la tio nship b e twe e n the RAI pro c e ss,

the c a re pla n, a nd q ua lity re side nt c a re

• Disc uss the re la tio nship b e twe e n the MDS, CAT

’ s, CAA’ s a nd the c a re pla n

• Disc us the

ro le

• f c ritic a l thinking

in the c a re pla nning pro c e ss

• L

ist the c o mpo ne nts o f a n e ffe c tive c a re pla n

• De fine “inte rim c a re pla n”
• Give a n e xa mple o f a n “IF
• rma t” c a re pla n

Ob je c tive s

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2/21/2017 3 I re me mbe r o nc e in my c are e r thinking to myse lf, “I sho uld pro bably go ask the re side nt what she thinks

• f this c are plan go al that I se t fo r he r,” but the n

de c iding I didn’t have time . S to p and think fo r a minute – Who se go als are the y? Who se c are plan is it? Who se life is it? Re me mbe r: What happe ns to a re side nt always has be e n and always will be abo ut

the irlife .

• Car

me n Bowman, F

• rme rCo lo rado De partme nt o f H

e alth S urve yo r

Who se Go a ls Are T he y Anywa y?

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T he c a re pla nning re q uire me nts re fle c t the fa c ility’ s re spo nsib ilitie s to pro vide ne c e ssa ry c a re pla nning tha t re sults in c a re a nd se rvic e s to a tta in o r ma inta in the hig he st pra c tic a b le physic a l, me nta l a nd psyc ho so c ia l we ll-b e ing fo r the re side nt.

I ntro duc tio n

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Ca re pla nning fo ste rs q ua lity re side nt c a re b y:

• F

a c ilita ting c o mmunic a tio n a mo ng the I nte rdisc iplina ry T e a m (I DT ) me mb e rs

• Pro viding

sta ff with c o nsiste nt info rma tio n a b o ut the re side nt's pro b le ms, stre ng ths, a nd ne e ds

• I

nstruc ting sta ff o n ho w to me e t the individua l re side nt’ s ne e ds

• Allo wing upda te s a nd re visio ns a c c o rding to the

re side nt's c ha ng ing ne e ds

• Inc luding the r

e side nt’s voic e and c hoic e

I ntro duc tio n

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T he c a re pla n must a im to a ddre ss the fo llo wing :

Ca re Pla n De ve lo pme nt

• Pre ve nt a vo ida b le de c line
• Ma na g e risk fa c to rs
• Addre ss re side nt stre ng ths
• E

va lua te tre a tme nt

• b je c tive s a nd c a re
• utc o me s
• Re spe c t the re side nt’ s

rig ht to re fuse tre a tme nt

• Offe r a lte rna tive

tre a tme nts

• Use a n inte rdisc iplina ry

a ppro a c h

• I

nvo lve the re side nt, fa mily, o r o the r re side nt re pre se nta tive

• I

nvo lve dire c t c a re sta ff in the pro c e ss

• Use c urre nt sta nda rds o f

pra c tic e

• CMS’ s RAI

Ve rsio n 3.0 Ma nua l, Cha pte r 4

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T he RAIPro c e ss c o nsists o f thre e b a sic c o mpo ne nts:

• T

he Minimum Da ta Se t (MDS) Ve rsio n 3.0

• T

he Ca re Are a Asse ssme nt (CAA) Pro c e ss

• T

he RAIUtiliza tio n Guide line s

Re side nt Asse ssme nt I nstrume nt (RAI ) Pro c e ss

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T he c ritic a l link b e twe e n the MDS 3.0 a nd c a re pla nning re sults fro m two ke y a re a s:

• Ca re Are a Asse ssme nts
• Ca re Are a T

rig g e rs

L inks in the (RAI ) Pro c e ss

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• Ca re

Are a T rig g e rs o r CAT s a re the trig g e ring me c ha nisms o f the MDS 3.0

• T

he y a re spe c ific re spo nse o ptio ns tha t se rve a s indic a to rs o f the twe nty c a re a re a s tha t a ffe c t nursing ho me re side nts.

• Whe n info rma tio n e nte re d into the MDS 3.0 trig g e rs

a re spo nse , a dditio na l a sse ssme nt a nd c a re a re a re vie w is re q uire d.

Wha t a re the CAT s?

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T he Ca re Are a Asse ssme nt (CAA) Pro c e ss is g uide d b y pro fe ssio na l sta nda rds o f pra c tic e a nd re g ula to ry re q uire me nts. I t is de sig ne d to g uide the I DT thro ug h the c o mpre he nsive a sse ssme nt o f a re side nt’ s func tio na l sta tus.

Wha t a re the CAA’ s?

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T he re a re 20 CAAs

CAAs

• De lirium
• Visua l F

unc tio n

• Ac tivity o f Da ily L

iving (ADL ) F unc tio na l/ Re ha b ilita tio n Po te ntia l

• Urina ry I

nc o ntine nc e a nd I ndwe lling c a the te r

• Psyc ho so c ia l We ll-Be ing
• Be ha vio ra l Sympto ms
• F

a lls

• F

e e ding T ub e s

• De nta l Ca re
• Psyc ho tro pic Me dic a tio n Use
• Co g nitive L
• ss/ De me ntia
• Co mmunic a tio n
• Pa in
• Re turn to Co mmunity

Re fe rra l

• Mo o d Sa te
• Ac tivitie s
• Nutritio na l Sta tus
• De hydra tio n/ F

luid Ma inte na nc e

• Pre ssure Ulc e r
• Physic a l Re stra ints

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• CAAs a re re q uire d fo r the fo llo wing c o mpre he nsive

c linic a l a sse ssme nts

• Admissio n Asse ssme nts
• Annua l Asse ssme nts
• Sig nific a nt Cha ng e in Sta tus Asse ssme nts
• Sig nific a nt Co rre c tio n o f Prio r F

ull Asse ssme nts

• CAAs ma y a lso b e use d a t a ny time , no t just whe n

a n a sse ssme nt is due , to pro vide in-de pth re vie w o f a c a re a re a c o nditio n to a ssist with de ve lo pme nt

• f a c a re pla n

Using the CAAs

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RAI Pro c e ss De sig n

Assessment (MDS 3.0) Decision Making (CAAs) Care Plan Development Care Plan Implementation Evaluation

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T he Bridg e fro m Asse ssme nt to Ca re Pla nning

• Co lle c ting a sse ssme nt da ta in itse lf is no t suffic ie nt

to de ve lo p a n e ffe c tive pla n o f c a re

• Unde rsta nding the re le va nc e o f the da ta to the

spe c ific re side nt’ s situa tio n is e sse ntia l

Critic a l T hinking

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T he Bridg e fro m Asse ssme nt to Ca re Pla nning

• De finition
• f

Cr itic al T hinking:

T he inte lle c tua l pro c e ss o f re a so ning , o f lo g ic a lly a na lyzing a ll a va ila b le da ta

• Pur

pose of Cr itic al T hinking: T

• e xplo re a situa tio n,

phe no me no n, q ue stio n, o r pro b le m to a rrive a t a hypo the sis o r c o nc lusio ns a b o ut it tha t inte g ra te s a ll a va ila b le info rma tio n a nd c a n, the re fo re , b e c o nvinc ing ly justifie d (K urfiss, 1988)

Critic a l T hinking

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Critic a l thinking inc lude s:

• I

nte g ra ting a ll a va ila b le info rma tio n a nd e limina ting irre le va nt info rma tio n

• Using re a so ning pro c e sse s
• E

xplo ring a situa tio n to a rrive a t a hypo the sis

• L
• g ic a lly a na lyzing da ta
• Arriving

a t re a so na b le c o nc lusio ns a b o ut the re side nt’ s sta tus, ne e ds, pro b le ms, a nd stre ng ths in

• rde r to c re a te a n e ffe c tive pla n o f c a re

Critic a l T hinking

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• T

he c a re pla n is drive n no t o nly b y ide ntifie d re side nt issue s a nd/ o r c o nditio ns b ut a lso b y a re side nt’ s uniq ue c ha ra c te ristic s, stre ng ths, a nd ne e ds.

• A c a re pla n tha t is b a se d o n a tho ro ug h

a sse ssme nt, e ffe c tive c linic a l de c isio n ma king , a nd is c o mpa tib le with c urre nt sta nda rds o f c linic a l pra c tic e c a n pro vide a stro ng b a sis fo r o ptima l a ppro a c he s to q ua lity o f c a re a nd q ua lity o f life ne e ds o f individua l re side nts. MDS 3.0 Ma nua l pa g e s 4-9, 10

Critic a l T hinking

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• A we ll de ve lo pe d a nd e xe c ute d a sse ssme nt a nd c a re

pla n:

• L
• o ks a t e a c h re side nt a s a who le huma n b e ing with

uniq ue c ha ra c te ristic s a nd stre ng ths;

• Vie ws the re side nt in distinc t func tio na l a re a s fo r the

purpo se o f g a ining kno wle dg e a b o ut the re side nt’ s func tio na l sta tus (MDS);

Critic a l T hinking

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• Give s the I

DT a c o mmo n unde rsta nding o f the re side nt;

• Re -g ro ups the info rma tio n g a the re d to ide ntify

po ssib le issue s a nd/ o r c o nditio ns tha t the re side nt ma y ha ve (i.e ., trig g e rs);

• Pro vide s a dditio na l c la rity o f po te ntia l issue s a nd/ o r

c o nditio ns b y lo o king a t po ssib le c a use s a nd risks (CAA pro c e ss);

Critic a l T hinking

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• De ve lo ps a nd imple me nts a n inte rdisc iplina ry c a re pla n

b a se d o n the a sse ssme nt info rma tio n g a the re d thro ug ho ut the RAI pro c e ss, with ne c e ssa ry mo nito ring a nd fo llo w-up;

• Re fle c ts the re side nt/ re side nt re pre se nta tive input a nd

g o a ls fo r he a lth c a re ;

Critic a l T hinking

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• Pro vide s info rma tio n re g a rding ho w the c a use s a nd risks

a sso c ia te d with issue s a nd/ o r c o nditio ns c a n b e a ddre sse d to pro vide fo r a re side nt’ s hig he st pra c tic a b le le ve l o f we llb e ing (c a re pla nning );

• Re -e va lua te s the re side nt’ s sta tus a t pre sc rib e d inte rva ls

(i.e ., q ua rte rly, a nnua lly, o r if a sig nific a nt c ha ng e in sta tus o c c urs) using the RAI a nd the n mo difie s the individua lize d c a re pla n a s a ppro pria te a nd ne c e ssa ry.

MDS 3.0 Ma nua l Cha pte r 4

Critic a l T hinking

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• F
• llo wing the de c isio n to a ddre ss a trig g e re d c o nditio n
• n the c a re pla n, ke y sta ff o r the I

DT sho uld sub se q ue ntly:

• Re vie w a nd re vise the c urre nt c a re pla n, a s ne e de d; a nd
• Co mmunic a te with the re side nt o r his/ he r fa mily o r

re pre se nta tive re g a rding the re side nt, c a re pla ns, a nd the ir wishe s.

MDS 3.0 Ma nua l Cha pte r 4

Critic a l T hinking

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• T

he o ve ra ll c a re pla n sho uld b e o rie nte d to wa rds: 1. Pre ve nting a vo ida b le de c line s in func tio ning o r func tio na l le ve ls o r o the rwise c la rifying why a no the r g o a l ta ke s pre c e de nc e (e .g ., pa llia tive a ppro a c he s in e nd o f life situa tio n). 2. Ma na g ing risk fa c to rs to the e xte nt po ssib le o r indic a ting the limits o f suc h inte rve ntio ns. 3. Addre ssing wa ys to try to pre se rve a nd b uild upo n re side nt stre ng ths. 4. Applying c urre nt sta nda rds o f pra c tic e in the c a re pla nning pro c e ss.

Critic a l T hinking

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5. E va lua ting tre a tme nt o f me a sura b le o b je c tive s, time ta b le s a nd o utc o me s o f c a re . 6. Re spe c ting the re side nt’ s rig ht to de c line tre a tme nt. 7. Offe ring a lte rna tive tre a tme nts, a s a pplic a b le . 8. Using a n a ppro pria te inte rdisc iplina ry a ppro a c h to c a re pla n de ve lo pme nt to impro ve the re side nt’ s func tio na l a b ilitie s. 9. I nvo lving re side nt, re side nt’ s fa mily a nd o the r re side nt re pre se nta tive s a s a ppro pria te .

Critic a l T hinking

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• 11. Asse ssing a nd pla nning fo r c a re to me e t the re side nt’ s

me dic a l, nursing , me nta l a nd psyc ho so c ia l ne e ds.

• 11. I

nvo lving the dire c t c a re sta ff with the c a re pla nning pro c e ss re la ting to the re side nt’ s e xpe c te d o utc o me s.

• 12. Addre ssing a dditio na l c a re pla nning a re a s tha t a re re le va nt

to me e ting the re side nt’ s ne e ds in the lo ng -te rm c a re se tting .

MDS 3.0 Ma nua l Cha pte r 4

I f yo u re a d thro ug h Cha pte r 4 o f the RAI 3.0 Ma nua l, the wo rd “individua l” is re pe a te d o ve r a nd o ve r – No t just with the Ca re Pla nning , b ut a lso with the CAAs.

Critic a l T hinking

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• T

he pro c e ss

• f

the RAI a sse ssme nts is the fo unda tio n o f c a re pla nning in lo ng -te rm c a re

• T

he full RAI Pro c e ss is de sig ne d to re sult in a pla n o f c a re tha t g uide s AL

L le ve ls o f the re side nt’ s c a re

g ive rs.

Ca re Pla n De ve lo pme nt

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T he Ho listic Vie w:

• T

he fa c ility is re spo nsib le fo r a ddre ssing a ll ne e ds a nd stre ng ths o f re side nts re g a rdle ss o f whe the r the issue is inc lude d in the MDS

• r

CAAs

[42CF R483.20(b )]

Ca re Pla n De ve lo pme nt

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• T

he RAI Ve rsio n 3.0 g uide s the nursing ho me te a m to vie w re side nts a s individua ls who c o nside r b o th q ua lity o f c a re a nd q ua lity o f life a s sig nific a nt a nd ne c e ssa ry.

• T

he RAI c o mpo ne nts pro mo te a re side nt-va lue d e mpha sis.

T he Ho listic Vie w

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• T

he inte rdisc iplina ry a ppro a c h influe nc e s the re side nt’ s e xpe rie nc e o f c a re b y impa c ting wo rk pra c tic e s o f the te a m.

• A

ho listic fo c us he lps the I DT g e ne ra te individua lize d, pe rso n-c e nte re d/ dire c te d pla ns o f c a re tha t g uide da y-to -da y c a re fo r re side nts

T he Ho listic Vie w

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CMS ha s de fine d six g e ne ra l c a re pla nning a re a s it c o nside rs use ful fo r nursing ho me s:

• F

unc tio na l Sta tus

• Re ha b ilita tio n/ Re sto ra tive Nursing
• He a lth Ma inte na nc e
• Disc ha rg e Po te ntia l
• Me dic a tio ns
• Da ily Ca re ne e ds

Ca re Pla n De ve lo pme nt

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F unc tio na l Sta tus:

• F

unc tio na l sta tus limita tio ns a re ide ntifie d using the MDS a nd CAT s

• All c o nditio ns re q uiring inte rve ntio n must a ppe a r
• n the

c a re pla n o nc e re vie we d in the CAAs pro c e ss

• T

he c o nditio ns ide ntifie d b y the RAI sho uld b e c le a rly linke d to pro b le ms a ddre sse d o n the c a re pla n.

Ca re Pla n De ve lo pme nt

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Re ha b ilita tio n/ Re sto ra tive Nursing

• Asse ss a nd

c a re pla n po te ntia l fo r a ll type s o f re ha b ne e ds

• Asse ss a nd c a re pla n fo r risks a nd c o mplic a tio ns
• Be a le rt to the ne e d fo r re fe rra ls

Ca re Pla n De ve lo pme nt

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He a lth Ma inte na nc e

• Mo nito ring o f dise a se pro c e sse s tha t c urre ntly a re

b e ing tre a te d

• I

nc lude sta b le a nd unsta b le c o nditio ns tha t ne e d mo nito ring

• I

f the re side nt is ta king me dic a tio ns fo r c o nditio ns, re g ula r mo nito ring

• f

e de ma , vita l sig ns, b lo o d g luc o se , e tc ., sho uld b e c a re pla nne d

• T

e rmina l c a re

• Spe c ia l tre a tme nts suc h a s dia lysis o r ve ntila to r

suppo rt

Ca re Pla n De ve lo pme nt

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Disc ha rg e Po te ntia l

• Asse ss a t a dmissio n, a nnua lly, a nd PRN
• I

n so me c a se s a sse ssme nt fo r disc ha rg e po te ntia l ma y ne e d to b e c o mple te d with e a c h MDS

• F
• c us o n wha t ne e ds to b e do ne in o rde r fo r the

re side nt to b e sa fe ly a nd suc c e ssfully disc ha rg e d

Ca re Pla n De ve lo pme nt

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Ca re Pla n sho uld inc lude :

• I

nte nt fo r the use o f the me dic a tio n

• No n-Pha rma c o lo g ic a l a ppro a c he s
• Go a ls o r e xpe c te d o utc o me fo r the re side nt
• Ho w to mo nito r the re side nt’ s pro g re ss re la tive to

tho se g o a ls

• Wha t a c tio ns to ta ke whe n the pro g re ss is no t a s

e xpe c te d

Ca re Pla n De ve lo pme nt: Me dic a tio ns

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Ca re Pla n sho uld inc lude :

• Po te ntia l a dve rse c o nse q ue nc e s tha t a ppe a r in F

DA Bla c k-Bo x Wa rning

• Re side nt ma y b e pa rtic ula rly susc e ptib le to
• Ma y b e ra re
• Ma y ha ve sudde n o nse t
• Ma y b e irre ve rsib le
• I

mpa c t physic a l func tio n

• I

mpa c t psyc ho so c ia l sta tus

• Othe rpo ssib le e ffe c ts
• Ac tio n to ta ke if a dve rse c o nse q ue nc e s o c c ur

Ca re Pla n De ve lo pme nt: Me dic a tio ns

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Se da tive s / Hypno tic s

• I

nc lude

• the r

inte rve ntio ns, suc h a s sle e p & hyg ie ne pro g ra ms, imple me nte d b e fo re a nd while using the se drug s

• Me tho ds fo r mo nito ring fo r a dve rse c o nse q ue nc e s

Gra dua l do se re duc tio ns

• T

iming a nd me tho d

• Wha t to

lo o k fo r in te rms o f po ssib le a dve rse c o nse q ue nc e s a sso c ia te d with ta pe ring

• f the

pa rtic ula rme dic a tio n

Ca re Pla n De ve lo pme nt: Me dic a tio ns

39

Da ily Ca re Ne e ds

• Da ily c a re ne e ds tha t a re spe c ific to the re side nt

a nd a re o ut o f the o rdina ry must b e a ddre sse d o n the c a re pla n

• Nursing

ho me sta ff must use the ir pro fe ssio na l judg me nt whe n ma king the se de c isio n

• I

t is impe ra tive to ta lk to dire c t c a re sta ff on all shifts to de te rmine the individua l re side nt c a re ne e ds fo r tha t shift.

Ca re Pla n De ve lo pme nt

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I n d e ve lo ping the ho listic c a re pla n, utilize a ll a va ila b le a sse ssme nt da ta . I n a dditio n to the RAI Asse ssme nts, o the r a sse ssme nts ma y inc lude :

• Admissio n Nursing Asse ssme nt
• Hydra tio n, I

&O, F a ll Risk Asse ssme nt, Risk fo r skin b re a kdo wn, Re sto ra tive Asse ssme nt a nd

• the r

nursing a sse ssme nts

Ca re Pla n De ve lo pme nt

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• Ho spita l H&P
• All a nc illa ry de pa rtme nt a sse ssme nts: SS, Ac tivitie s,

Die ta ry, e tc .

• L

a b & X-ra y re po rts

• Disc ussio n with re side nt a nd fa mily

Ca re Pla n De ve lo pme nt

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T he c a re pla n must b e pre pa re d b y a n inte rdisc iplina ry te a m tha t inc lude s the a tte nding physic ia n, a n R.N. with re spo nsib ility fo r the re side nt, a nd

• the r

a ppro pria te sta ff in disc ipline s a s de te rmine d b y the re side nt’ s ne e ds, a nd, to the e xte nt pra c tic a b le , the pa rtic ipa tio n o f the re side nt, the re side nt’ s fa mily

• r

the re side nt’ s le g a l re pre se nta tive . [42CF R483.20(k)(2)]

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

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• Pro fe ssio na l

disc ipline s, a s a ppro pria te to the re side nt, must wo rk to g e the r to pro vide the g re a te st b e ne fit to the re side nt.

• T

he me c ha nic s

• f

ho w the I DDT me e ts its re spo nsib ility to de ve lo p a n inte rdisc iplina ry c a re pla n a re a t the disc re tio n o f the fa c ility.

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

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• F

a c e -to -fa c e c a re pla ns me e ting s a re no t re q uire d.

• T

he physic ia n must pa rtic ipa te , a nd ma y a rra ng e fo r a lte rna tive me tho ds o f pro viding input, suc h a s

• ne -o n-o ne disc ussio ns a nd c o nfe re nc e c a lls.

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

45

Re side nt a nd fa mily pa rtic ipa tio n

• T

he nursing ho me must a ssist re side nts to pa rtic ipa te

• T

he nursing ho me must pro vide e no ug h time to info rma tio n e xc ha ng e a nd de c isio n ma king

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

46

2/21/2017 24

• T

he nursing ho me must ma ke a n e ffo rt to sc he dule c a re pla n me e ting s a t a c o nve nie nt time o f the da y fo r re side nts a nd the ir fa milie s.

• T

he re side nt ha s the rig ht to re fuse spe c ific tre a tme nts a nd to se le c t a mo ng tre a tme nt o ptio ns b e fo re the c a re pla n is imple me nte d.

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

47

While fe de ra l re g ula tio ns a ffirm the re side nt’ s rig ht to pa rtic ipa te in c a re pla nning a nd to re fuse tre a tme nt, the re g ula tio ns do no t c re a te the rig ht fo r a re side nt, le g a l surro g a te o r re pre se nta tive to de ma nd tha t the fa c ility use spe c ific me dic a l inte rve ntio n o r tre a tme nt tha t the fa c ility de e ms ina ppro pria te . Sta tuto ry re q uire me nts ho ld the fa c ility ultima te ly a c c o unta b le fo r the re side nt’ s c a re a nd sa fe ty, inc luding c linic a l de c isio ns. [42CF R483.20(k)(2)]

Ca re Pla n De ve lo pme nt: I nte rdisc iplina ry T e a m Appro a c h

48

2/21/2017 25

Altho ug h fe de ra l re g ula tio ns do no t pre sc rib e a spe c ific c a re pla n fo rma t, re g ula tio ns do ma nda te the c o mpo ne nts to b e inc lude d in a c a re pla n:

• Pro b le m L

ist / Pro b le m sta te me nts spe c ific to the individua l

• Me a sura b le o b je c tive s
• Me a sura b le time ta b le s

Ca re Pla n Co mpo ne nts

49

• I

nte rve ntio ns to a tta in o r ma inta in the re side nt’ s hig he st pra c tic a b le physic a l, me nta l, a nd psyc ho so c ia l we ll-b e ing

• I

nte rve ntio ns tha t wo uld b e re q uire d b ut a re no t pro vide d due to re side nt’ s re fusa l o f tre a tme nt

• Da te o f the e ntry, sig na ture o f the I

DT me mb e r, disc ipline re spo nsib le fo r imple me nta tio n

Ca re Pla n Co mpo ne nts

50

2/21/2017 26

T he Pro b le m Sta te me nt:

• F
• rmula te d b a se d o n c ritic a l a na lysis o f the

I DT a sse ssme nts, inc luding trig g e re d CAAs

• De fine s the issue s spe c ific to the re side nt’ s pro b le m

to fa c ilita te e ffe c tive g o a l se tting a nd de ve lo pme nt o f a ppro pria te inte rve ntio ns

• I

s NOTa re sta te me nt o f the me dic a l dia g no sis, b ut usua lly de fine s pro b le ms a rising fro m the me dic a l pro b le m.

Ca re Pla n Co mpo ne nts

51

T he Pro b le m Sta te me nt:

• Dise a se -re la te d pro b le m sta te me nt:
• Me dic a l Dia g no sis c o mb ine d

with sig ns/ sympto ms e xhib ite d b y the re side nt

• Diffic ulty with dre ssing in the mo rning RT Oste o a rthritis

AE B c o mpla ins o f disc o mfo rt while putting a rms in his sle e ve s a nd b utto ning the b utto ns.

• Oc c a sio na lly strike s o ut a t sta ff during c a re s RTde me ntia

AE B re q uire s slo w a ppro a c h a fte r simple e xpla na tio n o f pro c e dure s.

• Be c o me s SOB with a mb ula tio n RTCOPD AE

B a mb ula te s in 15 fo o t inc re me nts b e fo re re sting .

Ca re Pla n Co mpo ne nts

52

2/21/2017 27

T he Pro b le m Sta te me nt:

• Nursing Dia g no sis pro b le m sta te me nt:
• I

n pra c tic e , usua lly c o mb ine d with e tio lo g y to c re a te de sc riptive nursing dia g no sis sta te me nt

• Co nfusio n, a c ute
• Vio le nc e , dire c te d a t o the rs
• Physic a l mo b ility, impa ire d.

Ca re Pla n Co mpo ne nts

53

T he Pro b le m Sta te me nt:

• Nursing Dia g no sis pro b le m sta te me nt: E

xa mple

• Ac ute c o nfusio n RT se ve re pa in a nd e ffe c ts o f pa in

me dic a tio n AE B ina b ility to find ro o m inde pe nde ntly

• Vio le nc e

dire c te d a t

• the rs

RT Org a nic Bra in Syndro me AE B sla pping dire c t c a re sta ff while the y a re g iving c a re

• I

mpa ire d physic a l mo b ility RTSOB re la te d to CHF AE B una b le to wa lk mo re tha n 15 fe e t witho ut tiring , b e c o ming SOB.

Ca re Pla n Co mpo ne nts

54

2/21/2017 28

T he Pro b le m Sta te me nt:

• T

he func tio na l pro b le m sta te me nt sho ws ho w:

• T

he c o nditio n is a pro b le m fo r the re side nt, NOT ho w it c re a te s a pro b le m fo r the sta ff;

• T

he c o nditio n limits o r je o pa rdize s the re side nt’ s a b ility to c o mple te ta sks o f da ily living ; o r

• T

he pro b le m a ffe c ts the re side nt’ s we ll-b e ing in so me wa y

• Mr. Smith c a nno t find his ro o m inde pe nde ntly
• Mrs. Jo ne s sla ps the fa c e o f dire c t c a re sta ff while the y a re

g iving pe rso na l c a re

• Mrs. Bro wn is una b le to wa lk mo re tha n 15 fe e t b e c a use o f

sho rtne ss o f b re a th

Ca re Pla n Co mpo ne nts

55

T he Pro b le m Sta te me nt:

• MDS –Re la te d Pro b le m Sta te me nts
• Pro b le m sta te me nts sho uld re fle c t te rmino lo g y o f the

MDS

• E

tio lo g y & sig ns/ sympto ms (s/ s) ma y b e a dde d:

• Me mo ry/ re c a ll a b ility de fic it RT se ve re pa in & e ffe c ts o f

pa in me dic a tio n AE B ina b ility to find o wn ro o m.

• Physic a lly a b usive

b e ha vio ra l sympto ms RT de me ntia AE B sla pping dire c t c a re sta ff while the y g ive c a re .

• Sho rtne ss o f b re a th with impa ire d physic a l mo b ility RT

COPD AE B ina b ility to wa lk mo re tha n 15 fe e t.

Ca re Pla n Co mpo ne nts

56

2/21/2017 29

T he Pro b le m Sta te me nt:

• T

he func tio na l pro b le m sta te me nt sa mple fo r So c ia l Se rvic e s:

Co g nitio n; Mo o d; Psyc h-We ll Be ing ; Ac tivitie s; Psyc h Drug

• Mr. Smith misse s do ing thing s with his wife like the y

use d to re la te d to RT CVA, He miple g ia , Ap ha sia , a s e xhib ite d b y AE B lo ve s to pla y c a rds a nd is willing to le a rn ne w c a rd g a me s. He b e c o me s suspic io us a nd pa ra no id o f his wife a t time s a s to he r fa ithfulne ss to

• him. He ha s a Dx. Of de pre ssio n a nd is o n sc he dule d

Cita lo pra m.

Ca re Pla n Co mpo ne nts

57

T he Pro b le m Sta te me nt:

• Re g a rdle ss o f the

wo rking

• r fo rma t, the

pro b le m sta te me nt must c o nta in e no ug h info rma tio n to e nsure tha t inte rve ntio ns se le c te d a re re la te d to the true pro b le m

• E

xa mple : F

• r

a re side nt who fe ll, the pro b le m sta te me nts b e lo w wo uld re sult in diffe re nt inte rve ntio ns:

• F

a ll c limb ing o ut o f b e d una ssiste d

• Slippe d o n urine wa lking to b a thro o m.

Ca re Pla n Co mpo ne nts

58

2/21/2017 30

Go a l: Re a so na b le e xpe c te d o utc o me o f c a re b a se d

• n

the c o nte nt o f the spe c ifie d pro b le m whic h pro vide s pre c ise o b je c tio ns fo r the re side nt to me e t:

• Ac tio n-o rie nte d
• Go a l fo r the re side nt, no t fo r sta ff
• Me a sura b le
• T

ime -limite d

• I

ndividua lize d fo r e a c h re side nt

Ca re Pla n Co mpo ne nts: T he Go a l

59

Ac c o rding to the RAI Use r's ma nua l, the g o a l sta te me nt sho uld inc lude : a sub je c t, a ve rb , mo difie rs, a nd a time fra me .

Ca re Pla n Co mpo ne nts: T he Go a l

Subje c t Ve r b Modifie r s T ime F r ame

• Mr. Jo ne s

Will wa lk Up a nd d o wn five sta irs with the he lp o f o ne CNA using a g a it b e lt Da ily fo r the ne xt 30 da ys

60

2/21/2017 31

Additio na l E xa mple :

• Mr. Smith will wa lk 50 fe e t with a

fro nt whe e le d wa lke d, g a it b e lt, a nd limite d a ssist o f 1 pe rso n d a ily fo r the ne xt 30 da ys

• Sub je c t: Mr. Smith
• Ac tio n Ve rb : will wa lk
• Mo difie rs: 50 ft. with fro nt-whe e le d wa lke r, limite d

a ssist o f 1, g a it b e lt,

• T

ime F ra me : da ily fo r the ne xt 30 da ys.

Ca re Pla n Co mpo ne nts: T he Go a l

61

F ro m Pre vio us E xa mple s:

• Mr. Smith will find

his ro o m inde pe nde ntly with ve rb a l c ue s within 2 we e ks.

• Mrs.

Jo ne s will ha ve <2 e piso de s pe r da y

• f

sla pping dire c t c a re sta ff while the y a re g iving c a re b y Ma rc h 28, 2017.

• Mrs. Bro wn will wa lk 25 fe e t with supe rvisio n o f 1

pe rso n witho ut s/ s o f SOB b y June 14, 2017.

Ca re Pla n Co mpo ne nts: T he Go a l

62

2/21/2017 32

Re a so na b le ne ss o f the g o a l

• F
• r Mrs. Jo ne s, “no e piso de s o f sla pping with 24

ho urs” mig ht NOTb e a re a so na b le g o a l Re a listic time fra me :

• F

e de ra l re g ula tio ns re q uire d q ua rte rly re a sse ssme nt a t a minimum.

• Re side nt-spe c ific a sse ssme nt da ta sho uld dic ta te

ho w o fte n re a sse ssme nt sho uld b e do ne

• Mr. Smith mig ht ne e d 2 we e ks o f me d c ha ng e s,

b e ha vio r mo dific a tio n, e tc ., to re a c h inde pe nde nc e .

Ca re Pla n Co mpo ne nts: T he Go a l

63

• E

a c h pro b le m must ha ve a le a st o ne g o a l

• A pro b le m ma y ha ve mo re tha n o ne g o a l
• I

f Mrs. Bro wn is una b le to wa lk mo re tha n 15 fe e t RT SOB a nd hip pa in, a se c o nd g o a l wo uld a ddre ss the hip pa in.

• Re la te d pro b le ms ma y sha re the sa me g o a ls a nd

a ppro a c he s.

Ca re Pla n Co mpo ne nts: T he Go a l

64

2/21/2017 33

• E

xa mple o f c o mb ine d SS g o a l g e tting b a c k to Mr. Smith: 2 g o a ls fro m 1 c o mb ine d pro b le m

• A. Mr. Smith will pa rtic ipa te in a n c a rd g a me with his

wife we e kly b y 06/ 14/ 2017

• B. Mr. Smith will ha ve

no a dve rse drug re a c tio ns (ADR’ s) fro m the Cita lo pra m b y 06/ 14/ 2017.

Ca re Pla n Co mpo ne nts: T he Go a l

65

• I

nte rve ntio ns a re :

• I

nstruc tio ns to the I DT

• De ve lo pe d b y c o rre la ting a sse ssme nt da ta with g o a ls
• f c a re
• Spe c ific

to the individua l’ s pro b le ms, ne e ds, stre ng ths, a nd risks

• I

nte rdisc iplina ry, with a ssig ne d a c c o unta b ility

• Co nsiste nt with the e sta b lishe d pla n o f c a re
• Ba se d o n pro fe ssio na l sta nda rds o f q ua lity

Ca re Pla n Co mpo ne nts: I nte rve ntio ns

66

2/21/2017 34

Va ry in fo c us de pe nding o n de sire d o utc o me

• F

a c ilita te impro ve me nt in sta tus

• Pre ve nt a vo ida b le de c line in sta tus
• Pro vide pa llia tive c a re

Ca te g o rie s o f inte rve ntio ns to c o nside r inc lude :

• Asse ssme nts
• Ob se rva tio ns a nd mo nito ring
• Spe c ific

c linic a l a ppro a c he s de sig ne d to a c hie ve spe c ific o utc o me s

• Re side nt a nd fa mily te a c hing a c tivitie s

Ca re Pla n Co mpo ne nts: I nte rve ntio ns

67

I nte rve ntio ns a re instruc tio ns to the I DT whic h sho uld inc lude c o nc ise , fo c use d a c tio n sta te me nts

• f

dire c tio n re g a rding the re side nt’ s c a re :

• Ac tio n ve rb : Amb ula te
• Amo unt, dista nc e , q ua ntity, suc h a s “15 F

e e t”

• Me tho d o f to b e utilize d , suc h a s “with fro nt-whe e le d

wa lke r”

• F

re q ue nc y, whe n a ppro pria te , suc h a s “T I D”.

• Ad ditio na l c la rifying info rma tio n o r dire c tio n, suc h a s,

“with g a it b e lt a nd limite d a ssist o f 1 pe rso n”.

Ca re Pla n Co mpo ne nts: I nte rve ntio ns

68

2/21/2017 35

T he Ca re Pla n is the to o l fo r pro viding c o ntinuity o f c a re :

• All c a re g ive rs must b e info rme d a b o ut the de ta ils
• f the pla n initia lly a nd with a ny c ha ng e s
• Go a ls a nd inte rve ntio ns must b e c o mmunic a te d to

a ll c a re g ive rs c o nsiste ntly to e nsure tha t e ve ryo ne is wo rking with the sa me o utc o me s in mind

• Re side nt a nd fa mily must b e

inc lude d, a nd the fina l c a re pla n must b e disc usse d with the re side nt

• r the re pre se nta tive .

Ca re Pla n Co mmunic a tio n

69

An e ffe c tive syste m fo r c o nsiste ntly c o mmunic a ting c a re pla nning de c isio n to e ve ryo ne who ne e ds it is e sse ntia l to po sitive re side nt o utc o me s. I t c a nno t b e

• ve rsta te d ho w impo rta nt it is to inc lude dire c t c a re

sta ff in the pro c e ss.

Ca re Pla n Co mmunic a tio n

70

2/21/2017 36

F e de ra l re g ula tio ns link timing with a sse ssme nts

• Within 7 days of c omple tion o f the initia l Admissio n

Asse ssme nt

• Qua rte rly
• With Sig nific a nt c ha ng e in sta tus

E xc e ptio n: T he nursing ho me is re spo nsib le fo r a ddre ssing re side nt’ s ne e ds fro m the mo me nt o f a dmissio n b y de ve lo ping a n inte rim c a re pla n. [483.20(b )]

Ca re Pla n T ime F ra me s

71

I nitia tio n o f Ca re Pla nning pro c e ss upo n a dmissio n:

• Utilize

ho spita l disc ha rg e / tra nsfe r

• rde rs,

SNF a dmissio n o rde rs, initia l nursing a sse ssme nt.

• Sho uld a lso inc lude e no ug h info rma tio n a b o ut ADL

sta tus fo r sta ff to sa fe ly c a re o f the re side nt

Ca re Pla n T ime F ra me s: T he I nte rim Ca re Pla n

72

2/21/2017 37

• I

nc lude ro utine c a re instruc tio ns to ma inta in o r impro ve func tio na l a b ilitie s until c o mpre he nsive a sse ssme nt is c o mple te .

• Co nduc t

a n initia l CAA re vie w fo r ide ntifie d pro b le m o r po te ntia l pro b le m, suc h a s re stra int, inc o ntine nc e , de hydra tio n, fa lls, o r psyc ho tro pic drug use

Ca re Pla n T ime F ra me s: T he I nte rim Ca re Pla n

73

• Ca re pla n must a c c ura te ly re pre se nt the c a re to

b e de live re d a t a ny g ive n po int in time .

• Sho uld b e re -e va lua te d & re vise d o n a n o n-g o ing

b a sis to re fle c t c ha ng e s in the re side nt a nd c a re the re side nt is re c e iving (RAIuse r’ s Ma nua l, p. 2-42)

• Se rvic e s

pro vide d

• r

a rra ng e d must b e in a c c o rda nc e with e a c h re side nt’ s writte n pla n o f c a re .

Ca re Pla n T ime F ra me s: Sig nific a nt Cha ng e in Sta tus

74

2/21/2017 38

• Ca re pla nning is a pro c e ss tha t ha s se ve ra l ste ps tha t

ma y o c c ur a t the sa me time o r in se q ue nc e . T he fo llo wing ke y ste ps a nd c o nside ra tio ns ma y he lp the I DT de ve lo p the c a re pla n a fte r c o mple ting the c o mpre he nsive a sse ssme nt:

• Ca re Pla n g o a ls sho uld b e me a sura b le .
• T

he I DT ma y a g re e o n inte rme dia te g o a l(s) tha t will le a d to o utc o me o b je c tive s.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

75

• I

nte rme dia te g o a l(s) a nd o b je c tive s must b e pe rtine nt to the re side nt’ s c o nditio n a nd situa tio n (i.e ., no t just a uto ma tic a lly a pplie d witho ut re g a rd fo r the ir individua l re le va nc e ), me asur

able , and have a time fr ame for c omple tion or e valuation.

• Ca re pla n g o a l sta te me nts sho uld inc lude : T

he subje c t

(fir st or thir d pe r son), the ve rb, the modifie r s, the time fr ame , and the goal(s).

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

76

2/21/2017 39

• A se pa ra te c a re pla n is no t ne c e ssa rily re q uire d fo r

e a c h a re a tha t trig g e rs a CAA.

• Sinc e a sing le trig g e r c a n ha ve multiple c a use s a nd

c o ntrib uting fa c to rs a nd multiple ite ms c a n ha ve a c o mmo n c a use o r re la te d risk fa c to rs, it is a c c e pta b le a nd ma y so me time s b e mo re a ppro pria te to a ddre ss multiple issue s within a sing le c a re pla n se g me nt o r to c ro ss re fe re nc e re la te d inte rve ntio ns fro m se ve ra l c a re pla n se g me nts.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

77

• F
• r e xa mple , if impa ire d ADL

func tio n, mo o d sta te , fa lls a nd a lte re d nutritio na l sta tus a re a ll de te rmine d to b e c a use d b y a n infe c tio n a nd me dic a tio n-re la te d a dve rse c o nse q ue nc e s, it ma y b e a ppro pria te to ha ve a sing le c a re pla n tha t a ddre sse s the se issue s in re la tio n to the c o mmo n c a use s.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

78

2/21/2017 40

• T

he RN c o o rdina to r is re q uire d to sig n a nd da te the Ca re Are a Asse ssme nt (CAA) Summa ry a fte r a ll trig g e re d CAAs ha ve b e e n re vie we d to c e rtify c o mple tio n o f the c o mpre he nsive a sse ssme nt (CAAs Co mple tio n Da te , V0200B2).

• F

a c ilitie s ha ve 7 da ys a fte r c o mple ting the RAI a sse ssme nt to de ve lo p o r re vise the re side nt’ s c a re pla n.

• F

a c ilitie s sho uld use the da te a t V0200B2 to de te rmine the da te a t V0200C2 b y whic h the c a re pla n must b e c o mple te d (V0200B2 + 7 da ys).

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

79

• T

he 7-da y re q uire me nt fo r c o mple tio n o r mo dific a tio n

• f the c a re pla n a pplie s to the Admissio n, SCSA, SCPA,

a nd/ o r Annua l RAI a sse ssme nts.

• A ne w c a re pla n do e s no t ne e d to b e de ve lo pe d

a fte r e a c h SCSA, SCPA, o r Annua l re a sse ssme nt.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

80

2/21/2017 41

• I

nste a d, the nursing ho me ma y re vise a n e xisting c a re pla n using the re sults o f the la te st c o mpre he nsive a sse ssme nt.

• F

a c ilitie s sho uld a lso e va lua te the a ppro pria te ne ss o f the c a re pla n a t a ll time s inc luding a fte r Qua rte rly a sse ssme nts, mo difying a s ne e de d.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

81

• I

f the RAI (MDS a nd CAAs) is no t c o mple te d until the la st po ssib le da te (the e nd o f c a le nda r da y 14 o f the sta y), ma ny o f the a ppro pria te c a re a re a issue s, risk fa c to rs, o r c o nditio ns ma y ha ve a lre a dy b e e n ide ntifie d, c a use s ma y ha ve b e e n c o nside re d, a nd a pre limina ry c a re pla n a nd re la te d inte rve ntio ns ma y ha ve b e e n initia te d.

• A c o mple te c a re pla n is re q uire d no late r

tha n 7 da ys afte r the RAI

is c o mple te d.

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

82

2/21/2017 42

• Re vie w o f the CAAs a fte r c o mple ting the MDS ma y

ra ise q ue stio ns a b o ut the ne e d to mo dify o r c o ntinue se rvic e s.

• Co nditio ns tha t o rig ina lly trig g e re d the CAA ma y no

lo ng e r b e pre se nt b e c a use the y re so lve d, o r c o nside ra tio n o f a lte rna tive c a use s ma y b e ne c e ssa ry b e c a use the initia l a ppro a c h to a n issue , risk, o r c o nditio n did no t wo rk o r wa s no t fully imple me nte d .

CAA a nd Ca re Pla nning Cla rific a tio ns F ro m the MDS 3.0 Ma nua l

83

• On the Annua l a sse ssme nt, if a re side nt trig g e rs the sa me

CAA(s) tha t trig g e re d o n the la st c o mpre he nsive a sse ssme nt, the CAA sho uld b e re vie we d a g a in.

• E

ve n if the CAA is trig g e re d fo r the sa me re a so n (no diffe re nc e in MDS re spo nse s), the re ma y b e a ne w o r c ha ng e d re la te d e ve nt ide ntifie d during CAA re vie w tha t mig ht c a ll fo r a re visio n to the re side nt’ s pla n o f c a re .

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• T

he I DT with the input o f the re side nt, fa mily o r re side nt’ s re pre se nta tive de te rmine s whe n a pro b le m o r po te ntia l pro b le m ne e ds to b e a ddre sse d in the c a re pla n.

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• T

he RN Co o rdina to r fo r the CAA pro c e ss (V0200B1) do e s no t ne e d to b e the sa me RN a s the RN Asse ssme nt Co o rdina to r who ve rifie s c o mple tio n o f the MDS a sse ssme nt (Z0500).

• T

he da te e nte re d in V0200B2 o n the CAA Summa ry is the da te o n whic h the RN Co o rdina to r fo r the CAA pro c e ss ve rifie d c o mple tio n o f the CAAs, whic h inc lude s a sse ssme nt

• f e a c h trig g e re d c a re a re a a nd c o mple tio n o f the

lo c a tio n a nd da te o f the CAA a sse ssme nt do c ume nta tio n se c tio n.

• Se e Cha pte r 2 fo r de ta ile d instruc tio ns o n the RAI

c o mple tio n sc he dule .

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• T

he RN Co o rdina to r fo r the CAA pro c e ss (V0200B1) do e s no t ne e d to b e the sa me RN a s the RN Asse ssme nt Co o rdina to r who ve rifie s c o mple tio n o f the MDS a sse ssme nt (Z0500).

• T

he da te e nte re d in V0200B2 o n the CAA Summa ry is the da te

• n whic h the RN Co o rdina to r fo r the CAA pro c e ss ve rifie d

c o mple tio n o f the CAAs, whic h inc lude s a sse ssme nt o f e a c h trig g e re d c a re a re a a nd c o mple tio n o f the lo c a tio n a nd da te

• f the CAA a sse ssme nt do c ume nta tio n se c tio n.
• Se e Cha pte r 2 fo r de ta ile d instruc tio ns o n the RAI

c o mple tio n sc he dule .

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• T

he Sig na ture o f Pe rso n Co mple ting Ca re Pla n De c isio n (V0200C1) c a n b e tha t o f a ny pe rso n(s) who fa c ilita te s the c a re pla n de c isio n ma king . I t is a n inte rdisc iplina ry pro c e ss.

• T

he da te e nte re d in V0200C2 is the da y the RN c e rtifie s tha t the CAAs ha ve b e e n c o mple te d a nd the da y V0200C1 is sig ne d.

• MDS 3.0 Ma nua l Pa g e 4-11-12

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• Culture

Cha ng e is a b o ut tra nsfo rming nursing ho me s fo r b o th re side nts a nd sta ff. I t c re a te s “ho me ” within the nursing ho me thro ug h de sig na tio n o f ne ig hb o rho o ds, ra the r tha n units, with c o nsiste nt a ssig nme nts a nd re side nt-dire c te d c a re .

• Ca re pla nning is a pra c tic e b e ing influe nc e d b y

Culture Cha ng e . T wo ne we r type s o f c a re pla n fo rma ts a re :

• IF
• rma t Ca re Pla n
• F

ull Na rra tive F

• rma t Ca re Pla n

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89

‘ IF

• rma t’ Ca re Pla ns a re :
• Writte n in the voic e of the r

e side nt, a c tua lly using

the individua l’ s o wn sta te me nts

• Writte n so tha t c a re g ive rs c a n he a r the re side nt

spe a king whe n the y re a d the c a re pla n

I F

• rma t Ca re Pla n

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• Use d

fo r c o g nitive ly impa ire d re side nts b y inte rvie wing fa mily o r surro g a te s to le a rn the wishe s a nd life pre fe re nc e s o f the re side nt

• Ab le to me sh with b o th the RAI

’ s MDS 3.0 CAAs a nd the Qua lity I ndic a to r Surve y (QI S) inte rvie w pro c e sse s.

• Use c a re whe n using I
• F
• rma t c a re pla nning – Be

sure the y a re the re side nt’ s wo rds, no t o urs.

I F

• rma t Ca re Pla n

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Pr

• ble m / Ne e d

Goal Appr

• ac he s

I a m a t risk fo r skin b re a kdo wn due to my inc o ntine nc e I wa nt to re ma in fre e o f a ny skin pro b le ms 1. K e e p me c le a n a nd dry 2. Ipre fe r to turn e ve ry ho ur while I a m a wa ke 3. Do no t wa ke me a t nig ht to turn me . 4. I do no t wa nt to we a r b rie fs, b ut I will we a r a sma lle r pa d in my unde rwe a r 5. I ta ke Ditro pa n fo r b la dde r spa sms to c ut do wn o n le a king .

I F

• rma t Ca re Pla n

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• F

ull Na rra tive Ca re Pla ns a re writte n in pa ra g ra phs with re side nt-spe c ific info rma tio n tha t is e a sy to re a d.

• Whe n re a d fro m sta rt to finish, a full na rra tive c a re

pla n is simila r to re a ding a sto ry a b o ut the re side nt.

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All Ab o ut Me – My So c ia l Histo ry: My na me is Julia nne We lling to n, a nd I pre fe r to b e c a lle d Julia . I wa s b o rn

• n

a fa rm ne a r L e wisto n, NE o n De c e mb e r 8, 1930. My pa re nts we re immig ra nts fro m Sc o tla nd. My c hildho o d wa s simple a nd fun, a nd a ltho ug h life wa s to ug he r the n, it didn’ t se e m like it. I g ra dua te d fro m c o lle g e a nd b e c a me a te a c he r a t a c o untry o ne -ro o m sc ho o l ho use so uthe a st o f L e wisto n. I ma rrie d Pe te r We lling to n in 1948 a nd we ha d 4 c hildre n, a ll who live ne a rb y. Ho lida ys a nd b irthda ys a re impo rta nt to my fa mily, a nd Iwa nt to pa rtic ipa te in the m.

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Co mmunic a tio n / Me mo ry Go a l: I wa nt to ke e p my mind stimula te d to ma inta in my me mo ry, I like e ye c o nta c t, so ple a se lo o k a t me whe n yo u spe a k to me . I like disc ussing c urre nt e ve nts, so fe e l fre e to a sk me my o pinio n.

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Me nta l We llne ss Go a l: I wa nt to fe e l like I a m impo rta nt a nd ne e de d . I ha ve a lwa ys b e e n ve ry invo lve d in my surro unding s a nd wo uld like to ke e p it tha t wa y. I so me time s g e t disc o ura g e d a nd ma y fe e l like ke e ping to myse lf. Do n’ t ta ke this a s a pro b le m unle ss it la sts mo re tha n a we e k o r so . Do n’ t sc he dule a ppo intme nts o r b a ths fo r me during the se time s.

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Pe rso na l Ca re ADL s Go a l: Iwa nt to do a s muc h a s Ic a n fo r myse lf He a ring : My he a ring is g o o d

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Que stions? T HANK YOU

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Whe re to g e t mo re info rma tio n

MDS 3.0 Ma nua l V1.14 10/ 01/ 2016, Cha pte r 4 AANAC: AANAC.o rg Sta te Ope ra tio ns Ma nua l, Appe ndix P-PP, Surve y Guida nc e to Surve yo rs

• http:/ / www.c ms.hhs.gov/ manuals/ Downloads/ som107ap_p_ltc f.pdf
• http:/ / www.c ms.hhs.gove / ma nuals/ Downloads/ som107ap_pp_guide line s_ltc f.pdf

I nfo rma tio n So urc e s

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Re fe re nc e s:

MDS 3.0 Ma nua l V1.14, 10/ 01/ 2016

RE F E RE NCE S

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K a thy Sa nde rs RN, RAC-CT , DNS-CT Sa nde rs Co nsulting 630 N. 3rd St. T e c umse h, NE68450 ka thy@ mdshe lp.c o m Hm Offic e : (402) 335-2736 Ce ll: (402) 921-0250

T HANK YOU

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