Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure the participation of a resident and their representative in the development of the resident's care plan, as required by their policy and federal and state regulations. This deficiency was identified during a recertification survey, where it was found that the facility did not conduct interdisciplinary care plan meetings or provide notice of invitation to the resident or their representative for quarterly assessments. The facility's policy, revised in October 2024, mandates the creation of a comprehensive, individualized care plan for each resident, with active involvement from the resident and/or their legal representatives. However, the medical record for the resident in question lacked documented evidence of such invitations. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding care plan meetings. The Director of Social Work and other staff members confirmed that the facility only held care plan meetings for admissions, annuals, and significant change assessments, not for quarterly reviews. The Chief Nursing Officer was unaware that the interdisciplinary care plan team was not holding meetings for quarterly assessments. The resident involved, who had moderate cognitive impairment, expressed a desire to participate in the care planning process, but there was no evidence that they or their family were invited to do so.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #66 On 12/30/24, the IDCP Team held a meeting with the resident to review his/her plan of care and address any questions or concerns that the resident had. The resident indicated that he/she agreed with the current plan of care. The resident’s preference to be invited to and attend all care plan meetings was reviewed and documented in the resident’s record. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents could be potentially affected by the same practice. Effective 12/19/24, the IDCP Team will hold quarterly care plan reviews that includes the resident and/or representative. Residents and/or their representatives will continue to be invited to the other meetings. The IDT will meet with each resident who has had a Quarterly MDS Assessment in the past 3 months to provide an update on their plan of care. For residents who are unable to participate, the resident’s representative will be provided with an update to the plan of care. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer, and Director of Social Work reviewed the facility policy, “Care Planning,” and revised it to reflect the need to hold quarterly care plan meetings with the IDCP Team and ensure that the resident and/or representative are invited to participate. The IDCP Team was provided with education by the Director of Social Work regarding the revisions to the policy and changes to the facility’s care plan meeting protocol. All Social Workers were educated regarding the care planning process and their responsibility to ensure that residents have the right to participate in planning their care, including attending all care plan meetings. The Social Worker will ensure that all cognitively intact residents, including those who have been evaluated by Psychiatry and have can make their own decisions, and their representatives, as appropriate, are invited to all care plan meetings, including quarterly meetings. If the resident’s preference is to have a representative attend or be updated on the plan of care, this preference will be documented in the resident record and honored. The Social Worker will ensure that the representatives of residents who cannot or do not wish to participate in planning their care are invited to all meetings. Any resident who declines to participate will be provided with an update on the plan of care after the meeting if this is his/her preference. Members of the IDCP Team will follow up on concerns or questions as needed. The Social Workers were educated to document all care plan invitations and attendance, including for quarterlies, in the resident record. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: An audit tool will be developed to monitor compliance with the facility’s policy to ensure residents and/or their representatives are invited to participate in all care plan meetings, including quarterlies. Director of Social Work and/or Designee will conduct a 100% review of all care plan meeting attendance records to ensure that the resident and/or representative were invited to all care plan meetings, including quarterly meetings monthly for 3 months and then quarterly for an additional two quarters. The Director of Social Work will report all care plan meeting attendance findings to the Administrator. The audit findings will be reported monthly to the QAPI Committee for 3 months and then quarterly for 2 quarters for discussion, evaluation and follow-up action. The QAPI Committee will evaluate the need for continued monitoring at the end of the reporting period. The acceptable level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Director of Social Work