Failure to Conduct and Document Timely Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document care plan meetings of the interdisciplinary team for residents at the time of quarterly revisions of their care plans, as required. Review of medical records and interviews revealed that for four out of six residents reviewed, there was either no documentation of care plan meetings or the documentation did not align with the timing of the Minimum Data Set (MDS) assessments. Specifically, care plan meetings were not held or not documented within the required timeframes following quarterly or annual MDS assessments, and sign-in sheets or progress notes did not consistently match the assessment dates. Interviews with facility staff, including the DON and MDS coordinator, confirmed that care plan meetings should be scheduled in relation to MDS assessments and involve an interdisciplinary team. However, discrepancies were found between staff statements and actual practice, with staff unable to provide clear answers regarding the required timing for care plan reviews after MDS assessments. The deficiency was validated by the DON when concerns were presented by surveyors.