MDS Corner with Judy Bagby, RN

This week in MDS Corner- How Care Planning Fits with the RAI Process:

With OBRA 1987 a mandate was given to nursing facilities to provide the needed services to help every resident “attain or maintain their highest practicable well-being.”  A facility should have a process for a comprehensive standardized assessment of the resident’s capacities and needs.  With the use of the 3 main components of the RAI: 1) MDS, 2) CAAs, and 3) RAI Utilization Guidelines, the facility will design a plan of care to assist with each resident’s improvement. The goal is to eliminate avoidable declines.

During the monthly review of 2567 documents there has  been a noted increase in F279, F280, and F281 citations.  These deficiencies are for the development, participation and services related to care planning.  The RAI process is designed to assist with identifying a resident’s strengths and needs which are then placed in the resident’s individualized plan of care.  The care plan for an individual is much like a recipe used to prepare a food item. The recipe helps to achieve our goal of serving a specific item consistently.  Each care plan should be specifically tailored to the goals and interventions of the individual.

  The MDS is the first step to identifying a resident’s needs.  This process helps to see “the what” about the resident.  Accuracy in coding will assist with the various calculation processes that occur.  As a reminder it is also the payment tool and the survey tool.  It can also be the data used to influence potential customers.  The coders need to be educated on the intent of the item sets they contribute to.  The interdisciplinary team depends on accurate coding to design the plan of care.   The bridge between the care plan and the MDS is the CAA process.  The Care Area Assessment tools are helping to analyze the “why” which is needed to determine the need to care plan.  This is an area of the RAI process that is often overlooked or “cut short”.  It is important to do a root- cause analysis on the CAA triggered areas, since you may discover it is a system problem not the resident’s problem.  If it is a system problem it will affect others similarly.

  Care Planning is the process for implementing how to achieve or implement an action plan for a resident.  The RAI manual pages 1-9, 4-11 and 4-12, educates on the process that includes care planning.  Assessment, decision making, development, implementation and evaluations are the important steps for RAI success.  Frequently it is the evaluation step that is missed.  When a resident’s risk or problem is identified, an action takes place to resolve or improve the situation.  Education to those responsible for care must take place to provide consistency with the plan along with feedback for needed changes.   The RAI on 4-11, item 3 deals with not having to address each trigger independently but looks at common cause between items or risk factors.  The example given is impaired ADLs, mood state, falls and altered nutritional status and with analysis, may all be related to an infection and medication use.  It would be appropriate to have a single care plan problem dealing with all these risks.   The citations note that approaches are not being updated, including documentation to reflect date of initiation and changes.  If the review process is not ongoing but only occurs with the MDS schedule this risk will continue and there is the additional problem care givers are not doing what is needed for the resident success.  Outside resources used to meet the resident’s needs and their interventions need to be a part of the single resident care- plan.  Outside resources might include therapy, dialysis and hospice.    As we move more to the electronic health record there is an increased opportunity to have real time adjustments to the resident care plan.    Frequent review and adjustments will also assist with the management of items that affect payment, survey and quality dashboards.

  Remember the resident’s designated others, as well as all department staff, are important for success of the resident.  There will be times when the resident makes a choice that may cause questions or concerns.  It is important to have a care plan that helps all parties know how to reach the resident’s goal.   Sometimes we are so use do doing things a certain way that we forget to step back and say “why and is the outcome what we want.”  If you are not using the INTERACT resources I would encourage you to implement the tools.  Identifying problems early helps to limit declines and transfers to the hospital.  INTERACT has a good resource for Advanced Care Planning/End of Life Decisions.  Resident interaction can be different with different people so the use of an interdisciplinary team can help to have a accurate idea of the resident’s wishes and performance.  I would encourage a reread of Chapter 1 of the RAI Manual to review the purpose of the RAI process.