Comprehensive Plans

Comprehensive Care Plans are an OIG Focus Area and a survey and enforcement focus area. Failure to demonstrate an effective care planning process could be the basis for fraud and abuse or false claim actions. Below is a pictorial view of the care planning process and how it all works together.

Care Plans must meet needs of Residents, including:

Medical Needs;
Nursing Needs;
Mental Needs; and
Psychosocial Needs.

Care plans also must have:

Reasonable objectives based on resident:

diagnosis/medical psychosocial; and
preferences, needs and goals.

Timelines that are:

reasonable; and
attainable.

Key factors in an effective care plan include:

Interdisciplinary Approach:

All disciplines must be involved and must provide input based on discipline specific needs/goals; and
Documentation must be a disciplinary approach.

Basic steps for a successful care planning process include:

Scheduling meetings to accommodate full Interdisciplinary Team (IDT);
Completing all clinical assessments before meeting;
Open lines of communication to direct care providers and IDT;
Involvement of resident and family, Power of Attorney (POA) or guardian; and
Documentation of length and content of meeting.

Some of the key issues the OIG and CMS have focused on regarding scheduling meetings of the care planning team include:

The IDT must commit to care planning process by attending prescheduled meetings:

Don’t make excuses for absences,
Identify backup in the event of an emergency,
Don’t schedule other meetings/events that could interfere with participation, and
Be prepared and make sure appropriate information is available.

Care planning must be a priority. It certainly is an area of focus by federal/state enforcement agencies!

Here are some important points to remember which should occur prior to the care planning meeting:

IDT members should review assessments and medical record documentation (including activities of daily living (ADL) documentation, MARS, TARS, nurses’ notes, therapy notes, activities/social services notes, consults, labs, etc.);
Speak with direct care staff, physicians, physician extenders, other providers to obtain input and information;
Speak with family members/residents in advance of the meeting to better understand goals and objectives and to keep the meeting on track;
Assemble and organize all necessary documentation;
Develop an agenda to assure all critical areas are addressed; and
Alert staff and receptionist not to interrupt during the meeting.

In addition, the facility’s care planning team should encourage/invite:

direct care staff to participate at appropriate times to provide input and insight;
other ancillary providers to participate at appropriate times to provide input and insight; and
resident and family members to actively participate to express wishes, preferences, goals and objectives.

The care planning team also should:

Keep minutes of care plan meetings and have all parties review and sign;
Keep minutes that include start/top times, attendees, content of meeting;
Develop and document care plan goals during the meeting:

Make sure goals are specific, detailed, and understandable, and
Include time frames and expected outcomes.

Update nurse assignment sheets immediately following meeting to assure timely communication.

Some of the key issues the OIG and CMS have focused on regarding physician involvement include:

Physicians must be active in the care planning process; and
Documentation must evidence physician input and participation.

Some tips for facilitating physician involvement include:

Develop policies/procedures to require, accommodate, and encourage physician participation;
Provide advance notice of meetings;
Arrange for alternative approaches for participation;