Comprehensive Care Plan Process Flashcards

A surveyor is reviewing a resident's comprehensive care plan. Which of the following elements is required to be included according to federal regulations?

Answer: Measurable objectives and timeframes to meet the resident's needs.

According to 42 CFR §483.21, the comprehensive care plan must include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. While resident preferences and physician input are crucial, the specific requirement is for measurable goals and timelines.

During a survey, a team member notes that a new resident, admitted 72 hours ago, has a baseline care plan in their record. However, a comprehensive care plan has not yet been developed. How should the surveyor proceed?

Answer: Determine if the baseline care plan contains the minimum necessary information for the resident's immediate care.

Federal regulations at 42 CFR §483.21(a) require a baseline care plan to be developed within 48 hours of admission. This plan should include essential information like initial goals, physician orders, and dietary needs to ensure proper care until the comprehensive plan is completed. The surveyor's first step is to assess the adequacy of this baseline plan.

A resident with dementia is non-verbal and unable to participate in their care planning meeting. To comply with person-centered care planning requirements, which of the following is the facility's BEST course of action?

Answer: Ensure the resident's legal representative or family member participates in the process, and that the plan reflects the resident's known preferences.

Person-centered care requires that the facility actively involves the resident and/or their representative in the care planning process. When a resident cannot participate, the facility must include their representative to ensure the plan reflects the resident's values, preferences, and goals to the greatest extent possible.

A surveyor is reviewing the discharge planning component of a resident's comprehensive care plan. The plan should include documentation of which of the following?

Answer: An assessment of the resident's preference and potential for future discharge.

The regulations require that the comprehensive care plan, in consultation with the resident and their representative, documents the resident's preference and potential for future discharge. This includes assessing their desire to return to the community and making appropriate referrals if indicated.

Which of the following services, if required to meet a resident's needs, must be described in the comprehensive care plan?

Answer: Services that are culturally-competent and trauma-informed.

The regulations at §483.21(b)(3) and associated surveyor guidance emphasize that services outlined in the comprehensive care plan must be culturally-competent and trauma-informed. This ensures that care is respectful of and responsive to individual resident's preferences, needs, and values.

A facility develops a comprehensive care plan for a new resident within 48 hours of their admission. This plan includes measurable objectives, timeframes, and addresses all identified needs from the comprehensive assessment. In this scenario, the facility:

Answer: has met the requirements for both the baseline and comprehensive care plan timelines.

According to 42 CFR §483.21(a)(2), a facility may develop a comprehensive care plan in place of a baseline care plan if it is developed within 48 hours of admission and meets all the requirements of a comprehensive care plan. By doing so, they fulfill the initial planning requirement.