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
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;
- Attendance at the Meeting, or
- Post-meeting debriefing.
- Circulate minutes post-meeting;
- Circulate Care Plan drafts post-meeting;
- Solicit additional comments/suggestion; and
- Communicate final plan to physicians, other providers, direct care staff, etc.
The real keys to successful care planning are:
- Communication; and