Failure to Complete and Document Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly and that residents and their representatives were included in the development and implementation of person-centered care plans. For one resident with chronic obstructive pulmonary disease (COPD) who was moderately cognitively impaired and required substantial assistance with activities of daily living, the clinical record did not show evidence of a care plan conference since January, despite a quarterly MDS assessment in March. Although documentation was later provided indicating a care plan conference in April, the resident's power of attorney reported not being invited or included since January. Similarly, another resident with COPD and moderate cognitive impairment, who required supervision for daily activities, had no record of a care plan conference since November of the previous year, despite a quarterly MDS assessment in February. Documentation for a care plan conference in February was provided after the fact, and the Social Services Director acknowledged that care plan conferences should occur every three months and be documented in the clinical record, but in these cases, conferences had been backdated or documented late. Facility policy requires quarterly review and resident participation in care planning, which was not followed for these residents.