Comprehensive Care Plan Process Flashcards

During a survey, you observe that care plan conferences are held but family members consistently report not being invited. The most likely citation would be:

Answer: F-tag 656 (Comprehensive Care Plan) for failure to ensure participation

Failing to provide residents and representatives an opportunity to participate in care planning is a direct deficiency under F-tag 656.

A care plan correctly identifies a pressure injury but the interventions listed have not been updated despite documented wound progression. A surveyor would cite this as:

Answer: A deficiency because the care plan must be revised when conditions change

Care plans must be updated to reflect current status; failing to revise interventions when a wound progresses constitutes a care planning deficiency.

Which of the following best represents a person-centered care plan approach as emphasized in current CMS regulations?

Answer: Goals reflecting the resident's own preferences, strengths, and life history

CMS Phase 2 and 3 rules emphasize individualized, person-centered care plans that incorporate resident preferences, values, and goals.

A facility uses a computerized care plan system that auto-populates generic interventions from the MDS. A surveyor's concern with this practice would be:

Answer: Auto-populated plans may not be individualized to the specific resident

Even when using electronic systems, care plans must be individualized; generic auto-populated content that is not customized constitutes a deficiency.

If a surveyor finds that care plan goals are not being met and interventions are not being followed by staff, the root cause investigation should first examine:

Answer: Whether staff were educated on the care plan and whether the plan is accessible at point of care

Implementation failures often stem from staff not knowing about or having access to the care plan, making education and accessibility the first root cause to examine.

A resident requests that their care plan goal be changed from 'ambulate 50 feet daily' to 'remain in bed during evening hours.' The facility should:

Answer: Update the care plan to reflect the resident's preference and document any risks discussed

Residents have the right to participate in and direct their care; the facility must honor the preference and document informed decision-making.

Which statement about care plan signatures is most accurate under federal nursing facility regulations?

Answer: Regulations specify who must sign but do not require signatures from every discipline

CMS regulations require the care plan to be developed by the interdisciplinary team but do not mandate a specific signature block from every discipline.