SMQT Comprehensive Care Plan Process 2 — Questions and Answers
Question 1: Under federal regulations, how frequently must a nursing facility review and revise a resident's comprehensive care plan?
- Annually
- Every 90 days or after a significant change (Correct answer)
- Every 6 months
- Only when the resident requests it
Correct answer: Every 90 days or after a significant change
CMS requires care plans to be reviewed and revised quarterly or following a significant change in the resident's condition.
Question 2: Which interdisciplinary team member is primarily responsible for coordinating the comprehensive care plan meeting?
- The attending physician
- The Director of Nursing
- The Registered Nurse or designated care coordinator (Correct answer)
- The Social Worker
Correct answer: The Registered Nurse or designated care coordinator
A registered nurse or designated care coordinator typically organizes and leads the interdisciplinary care plan conference.
Question 3: A surveyor finds that a resident's care plan lists a goal of 'resident will not fall' but lacks specific interventions. This is a deficiency because:
- Goals must be written in medical terminology
- Care plans require measurable goals with corresponding interventions (Correct answer)
- Falls goals are not required by regulation
- Only physicians may write fall-prevention goals
Correct answer: Care plans require measurable goals with corresponding interventions
Regulations require care plans to include measurable objectives and specific interventions to address identified problems.
Question 4: When a resident is unable to participate in care plan development due to cognitive impairment, who must the facility involve?
- The State Ombudsman only
- The resident's legal representative or family member if no representative exists (Correct answer)
- Only the interdisciplinary team members
- The facility administrator
Correct answer: The resident's legal representative or family member if no representative exists
Federal regulations require facilities to involve the resident's legal representative or, if none, a family member when the resident cannot participate.
Question 5: A resident refuses a care plan goal. The facility's correct response is to:
- Override the refusal and implement the goal anyway
- Document the refusal and the risks explained, then respect the resident's right to refuse (Correct answer)
- Discharge the resident for non-compliance
- Remove the goal from the care plan without documentation
Correct answer: Document the refusal and the risks explained, then respect the resident's right to refuse
Residents have the right to refuse treatment; facilities must document informed refusal and any education provided about risks.
Question 6: Which of the following best describes a 'significant change in condition' that would trigger an unscheduled care plan revision?
- A minor bruise from a fall with no ongoing issues
- A documented decline in two or more ADLs that is not expected to resolve (Correct answer)
- A resident's birthday preference change
- A single elevated blood pressure reading
Correct answer: A documented decline in two or more ADLs that is not expected to resolve
A significant change requiring MDS reassessment—such as decline in multiple ADLs—also triggers a comprehensive care plan update.
Question 7: Under OBRA regulations, within how many days of admission must a comprehensive care plan be completed for a long-term care resident?
- 7 days
- 14 days
- 21 days (Correct answer)
- 30 days
Correct answer: 21 days
OBRA '87 requires a comprehensive care plan to be developed within 21 days of admission to a skilled nursing facility.
SMQT Comprehensive Care Plan Process 2
Under federal regulations, how frequently must a nursing facility review and revise a resident's comprehensive care plan?