Documentation Power Tools                                                   25 years experience in long term care

Basics and Standards of Care Planning 

In a skilled nursing facility, the care plan is the blueprint for the resident’s entire care needs, and directs the actions of all health care team members. A new staff member should be able to know everything essential about the resident by reading the care plan.

The care plan is a measure of quality of care. It gives a comprehensive picture of where the resident is at present and what is hoped to be achieved in the future. It is not only a guide for daily charting and care; it is also examined by surveyors to assess whether the resident’s needs are being adequately met by the facility.

The care plan: 

Increases consistency of care 

Focuses all interdisciplinary team members on the same problems 

Describes the resident’s functional abilities and needs 

         Sets goals to maintain the resident’s highest level of functioning 

        Addresses the resident’s physical, mental, emotional, and social needs 

        Provides a reference to measure progress or decline in the resident’s condition

Standards of Care Planning 

A number of clear guidelines and resources outline the basic components of a care plan for long term care. Being familiar with regulatory and industry standards helps to increase quality of care and assure good survey outcomes.  

The RAI MDS 2.0 User’s Manual is a reliable source of basic care-planning principles. In Chapter 5 of the manual, Linking Assessment to Individualized Care Plans, it states that: 

The process of care-planning is one of looking at the resident as a whole, building on the individual resident characteristics, measured using standard MDS items and definitions. 

The care plan should focus on the course of action needed to attain or maintain a resident’s highest practicable level of well-being, based on communication about the resident that is reliable, consistent, and understood by all team members. 

Good assessment forms the basis for a solid care plan. The RAPs serve as the link between the MDS and care planning. 

The care plan is driven by the resident’s problems, unique characteristics, strengths, and needs. 

The Code of Federal Regulations for Skilled Nursing Facilities provides a sound foundation of care-planning principles. It outlines what the Center for Medicare and Medicaid Services expects of skilled nursing facilities, and gives criteria used by surveyors during onsite facility inspections. 

Code of Federal Regulations (CFR) 42, Subpart E, Part 483.20   483.20 (b) Guidelines 

The facility is responsible for addressing all needs and strengths of residents regardless of whether the issue is included in the MDS or RAPs. The scope of the RAI does not limit the facility’s responsibility to assess and address all care needed by the resident. Furthermore, the facility is responsible for addressing the resident’s needs from the moment of admission.

F279  (k)Comprehensive Care Plans 

(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 

(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under 483.25; and 

(ii) Any services that would otherwise be required under 483.25 but are not provided due to the resident’s exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4). 

The American Nursing Association’s Standards of Clinical Practice outline the Nursing Process. This framework of critical analysis and planning is used universally by nurses in all areas of health care. Its six basic parts form the actual structure of the care-planning process: 

Assessment - data collection from the chart, physical nursing assessment, observation, interview of resident, family, and staff, review of the MDS data

Diagnosis – stating the individual problems as nursing diagnoses 

Outcome Identification / Planning– formulation of the desired goal for resolution of the problem, setting priorities, identifying nursing interventions

Implementation – putting the care plan into action

Evaluation – analyzing, assessing the success and appropriateness of the care plan

The written care plan is usually arranged into the three parts of Problem, Goal, and Interventions.

 More information about care plan conferences and writing care plans can be found in the book Complete Care Plans for Long Term Care