Failure to Ensure Resident Representative Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was able to participate in the development and implementation of the resident's person-centered care plan. The resident, who had diagnoses including Dementia, Alzheimer's Disease, and Major Depressive Disorder, was severely impaired in cognition and unable to meaningfully participate in care plan meetings. Despite this, the facility did not ensure that the resident's representative was properly invited to these meetings. The representative, who lived out of state, did not receive any invitation letters or calls from the facility, as the facility had been using an outdated address and phone number for the representative. The facility's Social Services Director assumed that invitations were delivered if they were not returned and did not follow up to confirm receipt or participation. The facility's records lacked evidence that care plan meeting invitations were mailed to the correct address or that the representative's contact information was verified. This oversight resulted in the representative being unaware of and unable to participate in the care plan meetings, contrary to the facility's policy and federal and state requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediately Corrective Action 1. Resident #36 representative was contacted and new information was obtained in order to ensure that the care plan meeting invitations were mailed and received by Resident #36’s representative by the Director of Social Service. 2. The Director of Social Service received a 1:1 inservice on the importance of ensuring that the resident and/or the resident’s representative participated in the development, review, and revision of the person-centered comprehensive care plan. This includes ensuring that the address the letter is mailed to is the most current contact information. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service and the MDS Coordinator compiled a list of residents in the last 30 days who have had a comprehensive care plan meeting to ensure a care plan meeting invitation was mailed and received by the resident’s representative. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS, and Director of Social Service reviewed and revised the policy & procedure for the Comprehensive Care Plan. 2. All Social Workers will be in-serviced by the Administrator/Designee on the revised policy and procedure. The lesson plan will focus on the Care Plan Meeting Invitation to the resident and the resident’s representative, the response to the letter, and accurate documentation. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that Care Plan Meeting Invitations are mailed to the resident’s representative, a response is received or follow-up is initiated and documented accordingly. 2. Audits will be done by the Director of Social Service/Designee on 10 random Care Plan Meeting Invitations for follow-up weekly x 4 weeks, 10 Care Plan Meeting Invitations monthly x 3 months, and 10 Care Plan Meeting Invitations quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow-up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible for overseeing this corrective action plan by 4/7/2025.