Living the Care Plan: Person-centered Care and the Revised CMS Regulations

Websites referenced during the Presentation:

Person-Centered Care Plan Practices 

  • Use Learning Circles to seek out input from those who will be affected by the change process
  • Consistent Assignments being done across all shifts - REALLY doing it
  • MDS and Care Plan Coordinator are the same person for each individual elder
  • Move location of Care Plan Coordinator’s office to be closer to the residents
  • Evaluate how the Baseline Care Plan is being used – who is using it? how is it being used? Is it accessible to those who need it?
  • Use All About Me / Life Stories to find out who the elder is
  • Use Huddle meetings to talk about newly admitted elders and to share information on all elders on an ongoing basis.
  • Evaluate how section F of the MDS is completed and how the information is used
  • Evaluate how all the interview sections of the MDS are completed
  • Review CAA process to assess if this is being done properly and used to care plan appropriately.
  • Evaluate all assessment forms being used for need, duplication, validity of info, etc.
  • Evaluate the Discharge Planning process to assess if this is person centered (tool being used, services being arranged, etc.)
  • Care Plan format: Resident writes care plan with you
  • Care Plan format: I Care Plans
  • Care Plan format: CNAs and other direct care staff write the approaches
  • Explain care planning upon admission to the elder/ significant other
  • Evaluate if the care plan invitation process lets the resident and the families understand the purpose of the meeting
  • Evaluate if there is a more streamlined approach to the care plan invitation process (i.e. who sends out the letters, who are RSVPs tracked, etc.)
  • Ask the resident who they want at the meeting and include that person/those people
  • Evaluate if the right people are attending the care plan meeting
  • Conduct the care plan meeting on the floor that the elder lives on
  • Conduct the care plan meeting in the elder’s room
  • Create a tool for the CNAs to provide care plan information for the care plan meeting
  • Ask the staff if they know what is on their residents’ care plans
  • Evaluate how the meeting is being conducted. (Does everyone feel included, is the process streamlined yet person centered?)
  • Use QAPI tool for MDS Sec. F, Person-Centered Care Tracking Tool to gain an understanding of the elders needs and satisfaction with getting these met (https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC#tab2)
  • Use stand up meetings to help convey what is going on with the elders
  • Use focused walking rounds and other coaching moments to help mentor the team and make sure the care plan is being used
  • Use the Clinical Pathway tools to evaluate how we are doing (Under downloads: LTC Survey Pathways https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html) 

Assessment Questions:  Thinking About What We Currently Do to Promote Person Centered Care Planning...

How do we approach change in our community? How are decisions made? Who writes/formulates the policies?


What does the Baseline Care Plan Process look like? Things to consider: How are they used? How is the elder and elder representatives involved? Do the Staff know the Baseline Care Plan ​and what services the individual needs and wants?


How is the assessment process structured including how it is done, who does it and what we do with the information we get?


How do we do discharge planning?


How are care plans written by all entities?


How is the care plan meeting structured?


How are elders and family invited to the care plan meeting?


Who attends the Care Plan meeting?


How is the direct care staff giving input on the elder?


How is the elder included in the care plan writing and the actual meeting?


How is the elder’s representative included in the care plan writing and actual meeting?


How does staff know what is on the care plan and how do they implement it?


When someone wants to do something against medical advice, what do we do?


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