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Care Planning: The Road

Map for Individualized

Resident Care

Kathy Sanders RN, RAC-CT, DNS-CT

Sanders Consulting

[email protected]

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The Care Planning: Care Planning: The Road Map for

Individualized Resident Care was developed as an

educational program and reference for long-term care

staff. To the best of our knowledge, it reflects current

federal regulations and practices. However, it cannot

be considered absolute and universal. The information

contained in this workshop must be considered in light

of the individual organization and state regulations. The

authors disclaim responsibility for any adverse effect

resulting directly or indirectly from the use of the

workshop material, from any undetected errors, and

from the user’s misunderstanding of the material.

Disclaimer

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The authors put forth every effort to ensure that the

content, including any policies, recommendations,

and sample documents used in this training, were in

agreement with current federal regulations,

recommendations, and practices at the time of

publication.

The information provided in this training is subject to

revision based on future updates and clarifications by

CMS.

Disclaimer Continued

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The learner will be able to:

• Describe the relationship between the RAI process, the care plan, and quality resident care

• Discuss the relationship between the MDS, CAT’s, CAA’s and the care plan

• Discus the role of critical thinking in the care planning process

• List the components of an effective care plan

• Define “interim care plan”

• Give an example of an “I Format” care plan

Objectives

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The care planning requirements reflect the facility’s

responsibilities to provide necessary care planning

that results in care and services to attain or maintain

the highest practicable physical, mental and

psychosocial well-being for the resident.

Introduction

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Care planning fosters quality resident care by:

• Facilitating communication among the Interdisciplinary Team (IDT) members

• Providing staff with consistent information about the resident's problems, strengths, and needs

• Instructing staff on how to meet the individual resident’s needs

• Allowing updates and revisions according to the resident's changing needs

• Including the resident’s voice and choice

Introduction

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RAI Process Design

Assessment (MDS 3.0)

Decision Making (CAAs)

Care Plan Development

Care Plan Implementation

Evaluation

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The care plan must aim to address the following:


• Prevent avoidable decline

• Manage risk factors

• Address resident strengths

• Evaluate treatment

objectives and care

outcomes

• Respect the resident’s

right to refuse treatment

• Offer alternative

treatments

• Use an interdisciplinary

approach

• Involve the resident,

family, or other resident

representative

• Involve direct care staff in

the process

• Use current standards of

practice

• CMS’s RAI Version 3.0

Manual, Chapter 4

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The RAI Process consists of three basic components:

• The Minimum Data Set (MDS) Version 3.0

• The Care Area Assessment (CAA) Process

• The RAI Utilization Guidelines

Resident Assessment Instrument (RAI) Process

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The critical link between the MDS 3.0 and care

planning results from two key areas:

• Care Area Assessments

• Care Area Triggers

Links in the(RAI) Process

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• Care Area Triggers or CATs are the triggering

mechanisms of the MDS 3.0

• They are specific response options that serve as

indicators of the twenty care areas that affect

nursing home residents.

• When information entered into the MDS 3.0 triggers

a response, additional assessment and care area

review is required.

What are the CATs?

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The Care Area Assessment (CAA) Process is guided

by professional standards of practice and regulatory

requirements.

It is designed to guide the IDT through the

comprehensive assessment of a resident’s functional

status.

What are the CAA’s?

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There are 20 CAAs

CAAs

• Delirium

• Visual Function

• Activity of Daily Living (ADL)

Functional/Rehabilitation

Potential

• Urinary Incontinence and

Indwelling catheter

• Psychosocial Well-Being

• Behavioral Symptoms

• Falls

• Feeding Tubes

• Dental Care

• Psychotropic Medication Use

• Cognitive Loss/Dementia

• Communication

• Pain

• Return to Community

Referral

• Mood Sate

• Activities

• Nutritional Status

• Dehydration/Fluid

Maintenance

• Pressure Ulcer

• Physical Restraints

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• CAAs are required for the following comprehensive clinical assessments

• Admission Assessments

• Annual Assessments

• Significant Change in Status Assessments

• Significant Correction of Prior Full Assessments

• CAAs may also be used at any time, not just when an assessment is due, to provide in-depth review of a care area condition to assist with development of a care plan

Using the CAAs

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The Bridge from Assessment to Care Planning

• Collecting assessment data in itself is not sufficient

to develop an effective plan of care

• Understanding the relevance of the data to the

specific resident’s situation is essential

Critical Thinking

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The Bridge from Assessment to Car Planning

• Definition of Critical Thinking: The intellectual

process of reasoning, of logically analyzing all

available data

• Purpose of Critical Thinking: To explore a situation,

phenomenon, question, or problem to arrive at a

hypothesis or conclusions about it that integrates

all available information and can, therefore, be

convincingly justified (Kurfiss, 1988)

Critical Thinking

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Critical thinking includes:

• Integrating all available information and

eliminating irrelevant information

• Using reasoning processes

• Exploring a situation to arrive at a hypothesis

• Logically analyzing data

• Arriving at reasonable conclusions about the

resident’s status, needs, problems, and strengths in

order to create an effective plan of care

Critical Thinking

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• The care plan is driven not only by identified

resident issues and/or conditions but also by a

resident’s unique characteristics, strengths, and

needs.

• A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. MDS 3.0 Manual pages 4-9, 10

Critical Thinking

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• A well developed and executed assessment and care plan:

• Looks at each resident as a whole human being with unique characteristics and strengths;

• Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident’s functional status (MDS);

• Gives the IDT a common understanding of the resident;

• Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers);

• Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process);

Critical Thinking

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• Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow-up;

• Reflects the resident/resident representative input and goals for health care;

• Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident’s highest practicable level of wellbeing (care planning);

• Re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. MDS 3.0 Manual pages 4-10

Critical Thinking

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• Following the decision to address a triggered condition on the care plan, key staff or the IDT should subsequently:

• Review and revise the current care plan, as needed; and

• Communicate with the resident or his/her family or representative regarding the resident, care plans, and their wishes. MDS 3.0 Manual pages 4-10

Critical Thinking

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• The overall care plan should be oriented towards:

1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation).

2. Managing risk factors to the extent possible or indicating the limits of such interventions.

3. Addressing ways to try to preserve and build upon resident strengths.

4. Applying current standards of practice in the care planning process.

Critical Thinking

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5. Evaluating treatment of measurable objectives, timetables and outcomes of care.

6. Respecting the resident’s right to decline treatment.

7. Offering alternative treatments, as applicable.

8. Using an appropriate interdisciplinary approach to care plan development to improve the resident’s functional abilities.

9. Involving resident, resident’s family and other resident representatives as appropriate.

10. Assessing and planning for care to meet the resident’s medical, nursing, mental and psychosocial needs.

Critical Thinking

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11. Involving the direct care staff with the care planning process relating to the resident’s expected outcomes.

12. Addressing additional care planning areas that are relevant to meeting the resident’s needs in the long-term care setting. MDS 3.0 Manual pages 4-10

If you read through Chapter 4 of the RAI 3.0 Manual, the word

“individual” is repeated over and over – Not just with the Care

Planning, but also with the CAAs.

Critical Thinking

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• The process of the RAI assessments is the

foundation of care planning in long-term care

• The full RAI Process is designed to result in a plan of

care that guides ALL levels of the resident’s care givers.


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The Holistic View:

• The facility is responsible for addressing all needs

and strengths of residents regardless of whether

the issue is included in the MDS or CAAs [42CFR483.20(b)]


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• The RAI Version 3.0 guides the nursing home team to

view residents as individuals who consider both quality

of care and quality of life as significant and necessary.

• The RAI components promote a resident-valued

emphasis.

• The interdisciplinary approach influences the resident’s

experience of care by impacting work practices of the

team.

• A holistic focus helps the IDT generate individualized,

person-centered/directed plans of care that guide

day-to-day care for residents

The Holistic View

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CMS has defined six general care planning areas it

considers useful for nursing homes:

• Functional Status

• Rehabilitation/Restorative Nursing

• Health Maintenance

• Discharge Potential

• Medications

• Daily Care needs


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Functional Status

• Functional status limitations are identified using the

MDS and CATs

• All conditions requiring intervention must appear

on the care plan once reviewed in the CAAs

process

• The conditions identified by the RAI should be

clearly linked to problems addressed on the car

plan.


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Rehabilitation/Restorative Nursing

• Assess and care plan potential for all types of

rehab needs

• Assess and care plan for risks and complications

• Be alert to the need for referrals


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Health Maintenance

• Monitoring of disease processes that currently are being treated

• Include stable and unstable conditions that need monitoring

• If the resident is taking medications for conditions, regular monitoring of edema, vital signs, blood glucose, etc., should be care planned

• Terminal care

• Special treatments such as dialysis or ventilator support


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Discharge Potential

• Assess at admission, annually, and PRN

• In some cases assessment for discharge potential

may need to be completed with each MDS

• Focus on what needs to be done in order for the

resident to be safely and successfully discharged


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Care Plan should include:

• Intent for the use of the medication

• Non-Pharmacological approaches

• Goals or expected outcome for the resident

• How to monitor the resident’s progress relative to

those goals

• What actions to take when the progress is not as

expected

Care Plan Development: Medications

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Care Plan should include:

• Potential adverse consequences that appear in FDA Black-Box Warning

• Resident may be particularly susceptible to

• May be rare

• May have sudden onset

• May be irreversible

• Impact physical function

• Impact psychosocial status

• Other possible effects

• Action to take if adverse consequences occur


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Sedatives / Hypnotics

• Include other interventions, such as sleep & hygiene programs, implemented before and while using these drugs

• Methods for monitoring for adverse consequences

Gradual dose reductions

• Timing and method

• What to look for in terms of possible adverse consequences associated with tapering of the particular medication


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Daily Care Needs

• Daily care needs that are specific to the resident

and are out of the ordinary must be addressed on

the care plan

• Nursing home staff must use their professional

judgment when making these decision

• It is imperative to talk to direct care staff on all

shifts to determine the individual resident care

needs for that shift.


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In developing the holistic care plan, utilize all available assessment data. In addition to the RAI Assessments, other assessments may include:

• Admission Nursing Assessment

• Hydration, I&O, Fall Risk Assessment, Risk for skin breakdown, Restorative Assessment and other nursing assessments

• Hospital H&P

• All ancillary department assessments: SS, Activities, Dietary, etc.

• Lab & X-ray reports

• Discussion with resident and family


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The care plan must be prepared by an

interdisciplinary team that includes the attending

physician, an R.N. with responsibility for the resident,

and other appropriate staff in disciplines as

determined by the resident’s needs, and, to the

extent practicable, the participation of the resident,

the resident’s family or the resident’s legal

representative. [42CFR483.20(k)(2)]

Care Plan Development:

Interdisciplinary Team Approach

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• Professional disciplines, as appropriate to the resident, must work together to provide the greatest benefit to the resident.

• The mechanics of how the IDDT meets its responsibility to develop an interdisciplinary care plan are at the discretion of the facility.

• Face-to-face care plans meetings are not required.

• The physician must participate, and may arrange for alternative methods of providing input, such as one-on-one discussions and conference calls.



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Resident and family participation

• The nursing home must assist residents to participate

• The nursing home must provide enough time to information exchange and decision making

• The nursing home must make an effort to schedule care plan meetings at a convenient time of the day for residents and their families.

• The resident has the right to refuse specific treatments and to select among treatment options before the care plan is implemented.



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While federal regulations affirm the resident’s right to

participate in car planning and to refuse treatment,

the regulations do not create the right for a resident,

legal surrogate or representative to demand that the

facility use specific medical intervention or treatment

that the facility deems inappropriate. Statutory

requirements hold the facility ultimately accountable

for the resident’s care and safety, including clinical

decisions. [42CFR483.20(k)(2)]



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Although federal regulations do not prescribe a specific care plan format, regulations do mandate the components to be included in a care plan:

• Problem List / Problem statements specific to the individual

• Measurable objectives

• Measurable timetables

• Interventions to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being

• Interventions that would be required but are not provided due to resident’s refusal of treatment

• Date of the entry, signature of the IDT member, discipline responsible for implementation

Care Plan Components

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The Problem Statement:

• Formulated based on critical analysis of the IDT

assessments, including triggered CAAs

• Defines the issues specific to the resident’s problem

to facilitate effective goal setting and

development of appropriate interventions

• Is NOT a restatement of the medical diagnosis, but

usually defines problems arising from the medical

problem.


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• Disease-related problem statement:

• Medical Diagnosis combined with signs/symptoms exhibited by the resident

• Difficulty with dressing in the morning RT Osteoarthritis AEB complains of discomfort while putting arms in his sleeves and buttoning the buttons.

• Occasionally strikes out at staff during cares RT dementia AEB requires slow approach after simple explanation of procedures.

• Becomes SOB with ambulation RT COPD AEB ambulates in 15 foot increments before resting.


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• Nursing Diagnosis problem statement:

• In practice, usually combined with etiology to create

descriptive nursing diagnosis statement

• Confusion, acute

• Violence, directed at others

• Physical mobility, impaired.


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• Nursing Diagnosis problem statement: Example

• Acute confusion RT severe pain and effects of pain

medication AEB inability to find room independently

• Violence directed at others RT Organic Brain

Syndrome AEB slapping direct care staff while they

are giving care

• Impaired physical mobility RT SOB related to CHF AEB

unable to walk more than 15 feet without tiring,

becoming SOB.


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• The functional problem statement shows how:

• The condition is a problem for the resident, NOT how it creates a problem for the staff;

• The condition limits or jeopardizes the resident’s ability to complete tasks of daily living; or

• The problem affects the resident’s well-being in some way

• Mr. Smith cannot find his room independently

• Mrs. Jones slaps the face of direct care staff while they are giving personal care

• Mrs. Brown is unable to walk more than 15 feet because of shortness of breath


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• MDS –Related Problem Statements

• Problem statements should reflect terminology of the

MDS

• Etiology & signs/symptoms (s/s) may be added:

• Memory/recall ability deficit RT severe pain & effects of

pain medication AEB inability to find own room.

• Physically abusive behavioral symptoms RT dementia

AEB slapping direct care staff while they give care.

• Shortness of breath with impaired physical mobility RT

COPD AEB inability to walk more than 15 feet.


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• The functional problem statement sample for Social

Services: Cognition; Mood; Psych-Well Being; Activities; Psych Drug

• Mr. Smith misses doing things with his wife like they

used to related to RT CVA, Hemiplegia, Aphasia, as

exhibited by AEB loves to play cards and is willing to

learn new card games. He becomes suspicious and

paranoid of his wife at times as to her faithfulness to

him. He has a Dx. Of depression and is on scheduled

Citalopram.


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• Regardless of the working or format, the problem

statement must contain enough information to

ensure that interventions selected are related to the

true problem

• Example: For a resident who fell, the problem

statements below would result in different

interventions:

• Fall climbing out of bed unassisted

• Slipped on urine walking to bathroom.


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Goal: Reasonable expected outcome of care based

on the content of the specified problem which

provides precise objections for the resident to meet:

• Action-oriented

• Goal for the resident, not for staff

• Measurable

• Time-limited

• Individualized for each resident

Care Plan Components: The Goal

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According to the RAI User's manual, the goal

statement should include: a subject, a verb,

modifiers, and a time frame.


Subject Verb Modifiers Time Frame

Mr. Jones Will walk Up and down

five stairs with

the help of one

CNA using a

gait belt

Daily for the

next 30 days

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Additional Example:

Mr. Smith will walk 50 feet with a front wheeled

walked, gait belt, and limited assist of 1 person daily

for the next 30 days

• Subject: Mr. Smith

• Action Verb: will walk

• Modifiers: 50 ft. with front-wheeled walker, limited

assist of 1, gait belt,

• Time Frame: daily for the next 30 days.


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From Previous Examples:

• Mr. Smith will find his room independently with

verbal cues within 2 weeks.

• Mrs. Jones will have <2 episodes per day of

slapping direct care staff while they are giving

care by July 22, 2015.

• Mrs. Brown will walk 25 feet with supervision of 1

person without s/s of SOB by August 25, 2015.


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Reasonableness of the goal

• For Mrs. Jones, “no episodes of slapping with 24 hours” might NOT be a reasonable goal

Realistic time frame:

• Federal regulations required quarterly reassessment at a minimum.

• Resident-specific assessment data should dictate how often reassessment should be done

• Mr. Smith might need 2 weeks of med changes, behavior modification, etc., to reach independence.


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• Each problem must have a least one goal

• A problem may have more than one goal

• If Mrs. Brown is unable to walk more than 15 feet RT

SOB and hip pain, a second goal would address the

hip pain.

• Related problems may share the same goals and

approaches.


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• Example of combined SS goal getting back to Mr.

Smith: 2 goals from 1 combined problem

• A. Mr. Smith will participate in an card game with his

wife weekly by 7/28/2015

• B. Mr. Smith will have no adverse drug reactions

(ADR’s) from the Citalopram by 7/28/2015.


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• Interventions are:

• Instructions to the IDT

• Developed by correlating assessment data with goals

of care

• Specific to the individual’s problems, needs,

strengths, and risks

• Interdisciplinary, with assigned accountability

• Consistent with the established plan of care

• Based on professional standards of quality

Care Plan Components: Interventions

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Vary in focus depending on desired outcome

• Facilitate improvement in status

• Prevent avoidable decline in status

• Provide palliative care

Categories of interventions to consider include:

• Assessments

• Observations and monitoring

• Specific clinical approaches designed to achieve

specific outcomes

• Resident and family teaching activities


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Interventions are instructions to the IDT which should

include concise, focused action statements of

direction regarding the resident’s care:

• Action verb: Ambulate

• Amount, distance, quantity, such as “15 Feet”

• Method of to be utilized, such as “with front-wheeled

walker”

• Frequency, when appropriate, such as “TID”.

• Additional clarifying information or direction, such as,

“with gait belt and limited assist of 1 person”.


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The Care Plan is the tool for providing continuity of

care:

• All care givers must be informed about the details

of the plan initially and with any changes

• Goals and interventions must be communicated to

all care givers consistently to ensure that everyone

is working with the same outcomes in mind

• Resident and family must be included, and the

final care plan must be discussed with the resident

or the representative.

Care Plan Communication

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An effective system for consistently communicating

care planning decision to everyone who needs it is

essential to positive resident outcomes. It cannot be

overstated how important it is to include direct care

staff in the process.

Care Plan Communication

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Federal regulations link timing with assessments

• Within 7 days of completion of the initial Admission

Assessment

• Quarterly

• With Significant change in status

Exception: The nursing home is responsible for

addressing resident’s needs from the moment of

admission by developing an interim care plan.

[483.20(b)]

Care Plan Time Frames

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Initiation of Care Planning process upon admission:

• Utilize hospital discharge/transfer orders, SNF admission

orders, initial nursing assessment.

• Should also include enough information about ADL

status for staff to safely care of the resident

• Include routine care instructions to maintain or improve

functional abilities until comprehensive assessment is

complete.

• Conduct an initial CAA review for identified problem or

potential problem, such as restraint, incontinence,

dehydration, falls, or psychotropic drug use

Care Plan Time Frames:

The Interim Care Plan

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• Care plan must accurately represent the care to

be delivered at any given point in time.

• Should be re-evaluated & revised on an on-going

basis to reflect changes in the resident and care

the resident is receiving (RAI user’s Manual, p. 2-40)

• Services provided or arranged must be in

accordance with each resident’s written plan of

care.

Care Plan Time Frames:

Significant Change in Status

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• Culture Change is about transforming nursing homes for both residents and staff. It creates “home” within the nursing home through designation of neighborhoods, rather than units, with consistent assignments and resident-directed care.

• Care planning is a practice being influenced by Culture Change. Two newer types of care plan formats are:

• I Format Care Plan

• Full Narrative Format Care Plan

Care Planning and Culture Change

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‘I Format’ Care Plans are the most popular of the new

formats. They are:

• Written in the voice of the residents, actually using the

individual’s own statements

• Written so that care givers can hear the resident

speaking when they read the care plan

• Used for cognitively impaired residents by interviewing

family or surrogates to learn the wishes and life

preferences of the resident

• Able to mesh with both the RAI’s MDS 3.0 CAAs and the

Quality Indicator Survey (QIS) interview processes.

I Format Care Plan

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Problem / Need Goal Approaches

I am at risk for skin

breakdown due to my

incontinence

I want to remain free of

any skin problems

1. Keep me clean and

dry

2. I prefer to turn every

hour while I am

awake

3. Do not wake me at

night to turn me.

4. I do not want to wear

briefs, but I will wear

a smaller pad in my

underwear

5. I take Ditropan for

bladder spasms to

cut down on leaking.

I Format Care Plan

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• Full Narrative Care Plans are written in paragraphs

with resident-specific information that is easy to

read.

• When read from start to finish, a full narrative care

plan is similar to reading a story about the resident.

Full Narrative Care Plan

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All About Me – My Social History:

My name is Julianne Wellington, and I prefer to be called

Julia. I was born on a farm near Lewiston, NE on

December 8, 1930. My parents were immigrants from

Scotland. My childhood was simple and fun, and

although life was tougher then, it didn’t seem like it. I

graduated from college and became a teacher at a

country one-room school house southeast of Lewiston. I

married Peter Wellington in 1948 and we had 4 children,

all who live nearby. Holidays and birthdays are important

to my family, and I want to participate in them.


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Communication / Memory

Goal: I want to keep my mind stimulated to maintain

my memory, I like eye contact, so please look at me

when you speak to me. I like discussing current

events, so feel free to ask me my opinion.


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Mental Wellness

Goal: I want to feel like I am important and needed.

I have always been very involved in my surroundings

and would like to keep it that way. I sometimes get

discouraged and may feel like keeping to myself.

Don’t take this as a problem unless it lasts more than

a week or so. Don’t schedule appointments or baths

for me during these time.s


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Personal Care ADLs

Goal: I want to do as much as I can for myself

Hearing: My hearing is good


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1. Care planning is a process that has several steps that

may occur at the same time or in sequence. The

following key steps and considerations may help the

IDT develop the care plan after completing the

comprehensive assessment:

a. Care Plan goals should be measurable.

b. The IDT may agree on intermediate goal(s) that will

lead to outcome objectives.

CAA and Care Planning Clarifications

From the MDS 3.0 Manual

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2. Intermediate goal(s) and objectives must be pertinent

to the resident’s condition and situation (i.e., not just

automatically applied without regard for their

individual relevance), measurable, and have a time

frame for completion or evaluation.

3. Care plan goal statements should include: The subject

(first or third person), the verb, the modifiers, the time

frame, and the goal(s).



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4. A separate care plan is not necessarily required for each area

that triggers a CAA.

a. Since a single trigger can have multiple causes and

contributing factors and multiple items can have a common

cause or related risk factors, it is acceptable and may

sometimes be more appropriate to address multiple issues

within a single care plan segment or to cross reference

related interventions from several care plan segments.

b. For example, if impaired ADL function, mood state, falls and

altered nutritional status are all determined to be caused by

an infection and medication-related adverse

consequences, it may be appropriate to have a single care

plan that addresses these issues in relation to the common

causes.



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5. The RN coordinator is required to sign and date the Care

Area Assessment (CAA) Summary after all triggered CAAs

have been reviewed to certify completion of the

comprehensive assessment (CAAs Completion Date,

V0200B2).

a. Facilities have 7 days after completing the RAI

assessment to develop or revise the resident’s care

plan.

b. Facilities should use the date at V0200B2 to determine

the date at V0200C2 by which the care plan must be

completed (V0200B2 + 7 days).

6. The 7-day requirement for completion or modification of the

care plan applies to the Admission, SCSA, SCPA, and/or Annual RAI assessments.



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a. A new care plan does not need to be developed after each SCSA, SCPA, or Annual reassessment.

b. Instead, the nursing home may revise an existing care plan using the results of the latest comprehensive assessment.

c. Facilities should also evaluate the appropriateness of the care plan at all times including after Quarterly assessments, modifying as needed.

7. If the RAI (MDS and CAAs) is not completed until the last possible date (the end of calendar day 14 of the stay), many of the appropriate care area issues, risk factors, or conditions may have already been identified, causes may have been considered, and a preliminary care plan and related interventions may have been initiated. A complete care plan is required no later than 7 days after the RAI is completed.



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8. Review of the CAAs after completing the MDS may raise questions about the need to modify or continue services. Conditions that originally triggered the CAA may no longer be present because they resolved, or consideration of alternative causes may be necessary because the initial approach to an issue, risk, or condition did not work or was not fully implemented.

9. On the Annual assessment, if a resident triggers the same CAA(s) that triggered on the last comprehensive assessment, the CAA should be reviewed again.

a. Even if the CAA is triggered for the same reason (no

difference in MDS responses), there may be a new or

changed related event identified during CAA review that

might call for a revision to the resident’s plan of care.



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b. The IDT with the input of the resident, family or resident’s representative determines when a problem or potential problem needs to be addressed in the care plan.

10. The RN Coordinator for the CAA process (V0200B1) does not need to be the same RN as the RN Assessment Coordinator who verifies completion of the MDS assessment (Z0500). The date entered in V0200B2 on the CAA Summary is the date on which the RN Coordinator for the CAA process verified completion of the CAAs, which includes assessment of each triggered care area and completion of the location and date of the CAA assessment documentation section. See Chapter 2 for detailed instructions on the RAI completion schedule.



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11. The Signature of Person Completing Care Plan Decision

(V0200C1) can be that of any person(s) who facilitates the

care plan decision making.

a. It is an interdisciplinary process.

b. The date entered in V0200C2 is the day the RN certifies

that the CAAs have been completed and the day

V0200C1 is signed. MDS 3.0 Manual Page 4-11, 12



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Questions?

THANK YOU

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Where to get more information

MDS 3.0 Manual V1.15, 10/01/2017, Chapter 4

AANAC: AANAC.org

State Operations Manual, Appendix P-PP, Survey Guidance to Surveyors

Information Sources

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References:

MDS 3.0 Manual V1.13, 10/01/2015

MDS Intensive Course Notes by Carol Maher RN, RAC-CT, AANAC MT, RAI

Manual Contributor.

REFERENCES

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Kathy Sanders RN, RAC-CT, DNS-CT

Sanders Consulting

630 N. 3rd St.

Tecumseh, NE 68450

Wk: (402) 335-2736 Cell: (402) 921-0250

[email protected]

THANK YOU

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