In the Reform of Requirements for Long-term Care Facilities Final Rule, the Centers for Medicare & Medicaid Services (CMS) established that a nurse aide (i.e. CNA) with responsibility for the resident must be part of the interdisciplinary team (IDT) that develops the resident’s person-centered comprehensive care plan and that reviews and revises (based on the resident’s changing goals, preferences, and needs, and in response to current interventions) the comprehensive care plan after each MDS assessment.
Note: CMS recently confirmed the requirement to review and revise the comprehensive care plan after both OBRA and PPS MDS assessments, except discharge assessments, in the revised Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training (See excerpt at the end of this article.) The review-and-revise component is important for two reasons:
1. As part of the Critical Element Decisions, multiple Critical Element Pathways used in the Long-term Care Survey Process (LTCSP) instruct surveyors to cite F657 (Care Plan Timing and Revision) if facilities fail to reassess the effectiveness of interventions and review and revise the care plan if necessary to meet the resident’s needs.
2. If surveyors identify concerns with timeliness and IDT/resident involvement in the development of care plans, the F657 interpretive guidance in Appendix PP of the State Operations Manual includes a set of probes to assist in their investigation. Two of the 11 probes directly assess IDT participation:
o Is there evidence of participation in the care planning process by required IDT members?
o Ask required members of the IDT how they participate in the development, review, and revision of care plans.
The F657 guidance gives providers significant latitude regarding how CNAs participate, stating: “The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record must reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate.”
In the Reform of Requirements Final Rule, CMS explains further: “We do not require that any of the members of the IDT participate in person. Facilities have the flexibility to determine how to hold IDT meetings, whether in person or by conference call. The facility may determine that participation by the nursing assistant, or any member, may be best met through email participation or written notes. We believe that this added flexibility will help to alleviate concerns of shortage and availability.”
However, CNA involvement is about more than meeting the explicit IDT participation requirements. The F657 guidance establishes the expectation that the IDT will “work together to provide the greatest benefit to the resident.” CMS discusses why including the CNAs in the IDT is important in the Reform of Requirements Final Rule: “Nursing assistants spend much of their time interacting directly with residents providing them day-to day care. In addition, their knowledge of a resident's care plan and medical needs directly relates to how well they can care for a resident and including them on the IDT may also contribute to improved outcomes.”
Steps that nurse assessment coordinators (NACs) can take to maximize CNA participation for the greatest benefit of the resident include the following:
Talk to the CNAs, especially during look-back periods
Some providers focus on having CNAs simply attend the care conference rather than getting them to participate in actual care plan development, says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, president/CEO of Celtic Consulting in Torrington, CT. “These facilities may not be including vital information in the plan of care related to: What is specific about this patient? How do they prefer to be cared for?” she points out.
“For example, a patient who worked nights their whole life probably won’t want to receive an early breakfast tray,” she explains. “Or a patient prefers to have the lights on when they go to sleep. CNAs work with residents daily, so they can help the IDT capture that type of individualized information to include in the person-centered plan of care and make sure you are meeting the needs and preferences of that resident.”
So during the window or look-back period of the assessment reference date (ARD), NACs should meet with the CNAs, recommends McCarthy. “Ask them about preferences for the resident or little nuances in their care, and identify certain points that would be important to the resident.”
NACs can do these interviews at the same time that they talk to the CNAs about data they need to collect and interpret for that ARD, such as the activities of daily living (ADLs), says McCarthy. “Not every CNA has a great handle on what the ADL definitions represent in real-life, on-the-floor resident scenarios. Talking with them during the ARD window will help you obtain a clearer picture of the resident’s clinical status and abilities for both MDS coding and care planning purposes, as well as giving you more information about the resident’s preferences.”
Follow up timely with CNAs post-interview
Sometimes NACs will collect information about what happened during the look-back period and then wait to interpret the information when coding the MDS, says McCarthy. “Once you’ve collected that information, it’s best to go back and talk to the CNAs again during the look-back period to work out inconsistencies and gain more resident-specific information when you have any questions. If you wait until after that window closes, it may be too late to correct the documentation that happened during the window or to even reach the specific staff member who completed that documentation for a clarification.”
Make in-person meeting attendance a facility priority too
While the F657 guidance doesn’t require the in-person participation of any IDT member in care conferences, having the CNAs attend care plan meetings in addition to participating in pre-meeting care plan development can be beneficial, says Beckie Dow, RN, RAC-MT, a nurse consultant in Largo, FL.
“It shouldn’t be an either/or scenario where talking to the CNAs prior to the meeting means that the CNAs skip the meeting itself,” she stresses. “CNA involvement in care plan meetings shows the patient as a customer that your team is a united front—that you communicate among yourselves as an IDT and that you’re working together for their recovery. When meetings are fractured, you may give the customer the impression that you don’t communicate well or that you aren’t organized in the way you provide care.”
To ensure CNA attendance, facility management must demonstrate the importance of care plan meetings, points out Dow. “You can make attendance part of CNAs’ routine assignments so they know to prioritize attendance just like they do anything else on their assignments.”
Don’t skip CNA participation in baseline care plans
CNAs should not only attend comprehensive care plan meetings, they should also participate in baseline care plan meetings, suggests Dow. “They can go in for a few moments at the beginning of the baseline care plan meeting, and then you can release them back to the floor to discuss other areas for the patient.”
Having the full IDT meet with the patient and/or their representative at bedside, or in the conference room if confidentiality is an issue, ultimately can help the IDT develop a better, more detailed comprehensive care plan, she says. “You present and summarize the baseline care plan, including current medications and dietary orders; provide a copy of their current physician orders; and say, ‘This is what we believe your needs are. Do you agree with this care plan, or do you think we have missed the mark in some area?’”
Like with the comprehensive care plan meetings, preparation is key, says Dow. “NACs should talk to the CNAs before the baseline care plan meeting as well. Doing that pre-work, even if it’s just a quick huddle about that patient, can help NACs anticipate some of the issues the CNAs will bring up.”
Also, there may be an opportunity for NACs to prompt the CNAs to discuss something in front of the patient and/or their representative, says Dow. “For example, if the patient was reluctant to participate in therapy or do a wound treatment, you can use that time in the baseline care plan meeting to help educate the patient and encourage them to participate in the treatments that will help them recover more quickly and more successfully. Or the CNA may know about ADL challenges that you can discuss briefly there in the baseline care plan meeting, and see if the nursing and therapy team can come up with any quick solutions that may help the patient recover better.”
If baseline care plan meetings threaten to run long due to an issue that arises, one option is to table the issue for later review, adds Dow. “Baseline care plan meetings should be brief. If the patient has a more in-depth issue they need to discuss, one option is to have ‘office hours’ for the relevant disciplines.”
For example, the dietary staff person may keep every Tuesday from 1 – 2 p.m. open, she explains. “Then if a dietary issue comes up during the baseline care plan meeting, you can offer the first patient who has a dietary issue a business card with that discipline’s name on it and assign them the 1 p.m. slot on the following Tuesday, and then the next patient gets the 1:15 slot, etc. This way, the dietary person can do a more detailed follow-up to address specific concerns with these patients, but the baseline care plan meeting will remain efficient.”
Be creative with meeting schedules
Providers often want to have CNAs physically present at care plan meetings, but scheduling can be a challenge, says Dow. “For example, sometimes care plan meetings take place when the CNAs are doing their morning personal care, and it isn’t an ideal time to pull them off the floor.”
So NACs should problem-solve the meeting schedule, suggests Dow. “You have to find a way to make these meetings easier on a CNA’s schedule. For example, you might try scheduling morning meetings in the hour just prior to lunch so that a.m. care is done, but the meetings won’t interfere with tray pass and feeding residents lunches.”
In addition, NACs should consider changing the order in which patients are scheduled, says Dow. “Providers often schedule one unit as a block and then the next unit as a separate block. As a result, a single primary CNA may have to attend four meetings during an hour-long block. Going back and forth like that can be disruptive and keep the CNA off the floor for a longer period of time. Another option is to try to rotate the units that have care plan meetings so that a single primary CNA might have only one meeting in an hour-long block.”
Don’t expect “I” care plans to be a silver bullet for person-centered care
“Some providers believe that using the ‘I’ care plan format automatically makes a care plan person-centered,” says McCarthy. “However, just replacing the words ‘The resident will’ or ‘Mrs. Smith will’ with ‘I will’ doesn’t make a care plan person-centered. You need to go the extra step and look at the preferences and concerns that are specific to this person. One way to start that process is to make sure the CNAs and other members of the care team are aware of the coding for Section F (Preferences for Customary Routines and Activities) starting with the 5-day PPS MDS so it’s reflected in all of your care planning discussions.”
Question: Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident’s care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.
Can you please confirm that a Care Plan review is required after each assessment for both OBRA and PPS assessments (with the exception of the discharge MDS)? And does this review require documentation that the review was completed.
CMS Answer: The regulation at 483.21(b)(2)(iii) (F657) states: “§483.21(b)(2) A comprehensive care plan must be—
… (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.”
Draft interpretive guidance at F657 states, ““After each assessment” means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) as required by §483.20, except discharge assessments.”
Additionally, you ask if the care plan review requires documentation. The expectation is that facilities can demonstrate that they have reviewed the care plan, even if no revisions are required. How facilities demonstrate this is up to each facility.
Source: Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training.
Editor’s note: CMS chose not to answer this question directly with a simple yes or no in the FAQ. However, a review of §483.20(b)(2) of the Code of Federal Regulations shows that PPS assessments are included as assessments that must be completed “when required” under SNF PPS per the regulations at §413.343(b). Since PPS assessments are required under §483.20(b)(2), the inference is that, yes, the interdisciplinary team must review and revise the comprehensive care plan after all OBRA and PPS assessments except discharge assessments.
The following note to surveyors excerpted from F657 in Appendix PP of the State Operations Manual points out the additional need to conduct ongoing clinical assessments and identify changes in condition between required MDS assessments:
NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health.
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Reviewed and revised on March 5, 2020