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Q&A: Has the care plan format changed from a problem, goal, and approaches model to a narrative structure?

By Jane Belt, RN, MS, RAC-MT, RAC-CT, QCP - May 01, 2018

Question: Has the care plan format changed from a problem, goal, and approaches model to a narrative structure? I know that the care plan MUST be individualized and resident centered, but recently a federal surveyor was looking for a narrative care plan and I was confused.

Answer: The components of a care plan have not changed and include:

·         Problem/Need/Strength

·         Measurable Goal/ Target Date

·         Interventions/Approaches

·         Discipline(s) Accountable for the Intervention.

There is no mandated format for the care plan. In fact, there are several formats that are used. including but not limited to the I Plan, narrative, problem-based (regarding specific MDS items), and nursing diagnosis. The format must work for the team and the resident must be able to understand it, as the resident has the right to review and sign.

The person-centered components are not determined so much by the format, but how the problems or needs and goals are stated. For example, what does the resident want? What is the resident's goal? What interventions does the resident want to try? It is the resident’s care plan.

From the regulation:
Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home.

In the Appendix PP (on AANAC's web site), you might want to refer to F656 and read through the intent, definitions, and guidance, as well.

There also is an investigative summary and probe section, which guides the surveyor in their investigation of a care plan concern. This includes the following questions:

  • Does the care plan address the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline?
  • Are objectives and interventions person-centered, measurable, and do they include time frames to achieve the desired outcomes?
  • Is there evidence of resident and, if applicable resident representative participation (or attempts made by the facility to encourage participation) in developing person-centered, measurable objectives and interventions?
  • Does the care plan describe specialized services and interventions to address PASARR recommendations, as appropriate?
  • Is there evidence that the care plan interventions were implemented consistently across all shifts?
  • Is there a process in place to ensure direct care staff are aware of and educated about the care plan interventions?
  • Determine whether the facility has provided adequate information to the resident and if applicable resident representative so that he/she was able to make informed choices regarding treatment and services.
  • Evaluate whether the care plan reflects the facility's efforts to find alternative means to address care of the resident if he or she has refused treatment.

You may also want to talk to the surveyor with your DNS to ask where the regulations state that the care plan must be written in a narrative format

Want to read more FAQs? Visit the AANAConnect community , where 14,000+ of your peers and experts in long-term care are asking and answering tough questions just like this.

Reviewed 12/4/19

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