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Long-Term Care Survey Alert

QUALITY OF CARE:

Step Up Care Plan QualityWith These 4 Key Strategies

Published on Thu May 21, 2009

Get a step ahead of the F309 survey guidance.

You don't want a surveyor to be the one to let you know that a resident or his family seems clueless about the care plan or, worse, complains it isn't working. And you can bet that surveyors using the new F309 general investigative protocol will be able to tell that and much more about the quality of the facility's care planning. Follow these best-practice approaches to ensure your care plans are on the mark -- and earn high marks from residents, their families, and surveyors.

Assess the Resident's Ability to Participate in Care Planning

Surveyors will be looking to see if the care plan incorporates the resident's goals, choices, and preferences. If the care plan team doesn't assess a resident's ability to establish his own goals (which you code at F1d on the MDS), it misses out on an opportunity to involve the resident in setting care plan goals, cautions Cheryl Field, MSN, RN, CRRN, a senior healthcare specialist with PointRight Inc. in Lexington, Mass. And if you don't identify a resident's strong identification with his past roles,coded at F3a, the team may overlook an important motivator for the person to achieve his goals, she adds.

Best bet: Assess and code these items correctly and make sure the care plan team incorporates these resident strengths in the care plan process, advises Field. Also include the discussion about these areas with the resident and family, she adds.

Heads up: Some conversational residents with dementia may appear to surveyors as if they have the cognitive ability to participate in their care planning when they actually don't. To assess whether someone can participate, determine their cognitive functional age, suggests Diana Waugh, RN, BSN, a consultant in Waterville, Ohio. To do that, you can use the Reality Comprehension Clock Test, which requires the test taker to look at a picture of a clock and replicate it to the best of her ability (for details, go to www.clocktestrcct.com). Another option is the Functional Assessment Staging (FAST) tool, which is designed for people with Alzheimer's disease.(View the tool at http://ec-online.net/Knowledge/articles/alzstages.html.)

Develop a Resident/Family-Friendly Care Plan Process

In one facility, the care team finds it works well to conduct the meeting in the resident's room at a time when his roommate is engaged in another activity, reports Waugh.The team also asks the resident's CNAs to be present during the bedside meeting to share their input."The families love it because they don't have to attend a meeting in a separate room," Waugh notes. And "being at the bedside also allows the team to do some assessment."

Keep it simple: Make sure to use lay terminology when interacting with residents and their families, suggests JoWalters, RN, a quality assurance nurse with a major nursing home chain in Toledo, Ohio. As a quality check, ask someone on the care planning team to monitor how many times the team members use acronyms like ADLs or speak medicalese when communicating with the resident or family. Also provide time to validate what the resident or his responsible person understands about the diagnosis and care plan, Walters advises. "You have to do this in a non-threatening way," she says. "Let them know that ... the information is difficult for anyone [to learn], and the team is there to help them understand and answer questions."

Can the 'Canned' Care Plans

Generalized care plans don't work. Instead, make sure the care plan paints a picture of the resident,advises Mardy Chizek, RN, FNP,BSN, MBA, a legal nurse consultant in Westmont, Ill. Also individualize the plan. "If the care plan includes a directive to encourage the resident to talk about what he likes, fill in the blank with dogs or quilting, etc.,"advises Waugh.

Tip: Each nurse in the facility might grab a care plan once a week and talk about the care plan with the resident's direct care providers, advises Waugh. The nurse might ask them if it seems to reflect the resident and seems to be on target. "If not, set up a time to get input for fixing it."

When the Care Plan Fails, Try,Try Again

The new F309 general investigative protocol directs surveyors to ask residents or their representatives if they think the care plan interventions have been effective -- and, if not,whether the facility has tried alternate approaches.

Take home message: When the resident continues to fall or the pressure ulcers aren't healing, as examples,the team really needs to ramp up its efforts, advises Chizek. And get the resident and/or his representative's input. "Talk to the person about the interventions, and what the staff has tried [and is going to try next]," advises Chizek.

"Spend your energy and time on the high-risk quality issues," such as a clinical problem that's not improving or getting worse.

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