9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 1 MDS 3.0 Care Planning Presented by Debbie Ohl RN, M.Msc., PhD. Ohl and Associates Committed to Quality Care & Professional Excellence 613 Compton Road Cincinnati, Ohio 45231 MDSCarePlanBuilder.com From Paper to Person Debbie Ohl RN, M.Msc., PhD Ohl and Associates Long Term Care Consultants [email protected]Debbie’s 30 year consulting practice is an outcome of learning lessons the hard way as a nursing director, sometime nurse’s aide and behind the scenes administrator. She is a regulatory compliance and interdisciplinary care planning specialist, authoring more than a dozen manuals including HcPro’s, Big Book of Care Plans. As a nationally recognized expert, Debbie has presented for many prestigious organizations including the National Institute for Health , the American College of Nursing Home Administrators, the National Health Care Lawyer’s Association, and numerous Health Care Organizations, and Nursing Facilities throughout the country. Recently completing her Ph.D in Holistic Life Coaching, Debbie brings a unique perspective on the impact that thoughts, feelings, and actions have on ourselves and those we serve. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Quality … Degree of excellence or worth Life… A manner or way of existing Autonomy… Self-governance, self-sufficiency Quality of Life Quality of Life Quality of Life Quality of Life RAI… The path to improvement.
Transcript
1. 9/22/2010 From Paper to Person MDS 3.0 Care Planning
Presented by Debbie Ohl RN, M.Msc., PhD. Ohl and Associates
Committed to Quality Care & Professional Excellence 613 Compton
Road Cincinnati, Ohio 45231 MDSCarePlanBuilder.com Debbie Ohl RN,
M.Msc., PhD Ohl and Associates Long Term Care Consultants
[email protected] Debbies 30 year consulting practice
is an outcome of learning lessons the hard way as a nursing
director, sometime nurses aide and behind the scenes administrator.
She is a regulatory compliance and interdisciplinary care planning
specialist, authoring more than a dozen manuals including HcPros,
Big Book of Care Plans. As a nationally recognized expert, Debbie
has presented for many prestigious organizations including the
National Institute for Health , the American College of Nursing
Home Administrators, the National Health Care Lawyers Association,
and numerous Health Care Organizations, and Nursing Facilities
throughout the country. Recently completing her Ph.D in Holistic
Life Coaching, Debbie brings a unique perspective on the impact
that thoughts, feelings, and actions have on ourselves and those we
serve. Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Quality of Life Quality
Degree of excellence or worth Life A manner or way of existing
Autonomy Self-governance, self-sufficiency RAI The path to
improvement.Debbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 1
2. 9/22/2010 Getting to the Care Plan MDS 3.0 CATs CAAs Debbie
Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives
Identify and discuss 3 to 5 new terms used in conjunction with the
MDS 3.0 and how they can be used in care planning. Issue Problem
CPGs PCP CPS PHQ-9 EBPs BIMS Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com Program Objectives Discuss the expectations of
person centered care planning. Discipline Specific Person / S.O.
Professionals Wishes/Preferences Human Being Resident
Administration Regulators Staff Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 2
3. 9/22/2010 Program Objectives Identify the seven components
of the care plan and at least one key factor of each as it relates
to RAI expectations. Debbie Ohl & Associates LTC Consultants
& Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program
Objectives Discuss the three primary content areas to be considered
in care planning. Impact on function Active Disease Impact on life
style 18 CAAs 2 Physical Accommodation Cognitive of Need
Psychosocial Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Evolution of
Care Planning Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl
& Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 3
4. 9/22/2010 1935 1965 Poor houses Medicare/Medicaid programs
funded by Feds SSA established public assistance Standards put in
place For profit homes proliferate 1970 1950 NH atrocities hit
front page of news SSA requires States to license papers NH SSA
does not specify 1972 Comprehensive Welfare Reform Act enforcement
standards funds state survey and certification to 1956 establish
uniform standards and conditions. Feds find NH substandard Emphasis
is on institutional framework: CAPACITY to deliver care. Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Mid 70s-early 80s
Patient Care & Services Survey born to correct emphasis on
capacity to deliver to ACTUAL delivery of care. Controversy over
legitimacy. Paper compliance in the form of policies was nearing
its end. 1975-76 Use of paper in the form of care plan takes center
stage to insure care delivery.... or at least begins the process.
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Phase 1 Phase II 1987
Paper to Person 1976-1987 Interdisciplinary Team Building QUALITY
of CARE EVERY resident must have a plan. EACH discipline must have
a plan. OBRA solidifies standards and creates a Every diagnosis
must be on plan. framework for continuity of care. All medications
must be on the plan. Care plan goals, interventions and Total
Confusion target dates progressively used to site deficiencies.
Emphasis is on Quality of Care. Result: Multi-disciplinary Unified
care planning efforts begin conflict, with name change to IDT.
fragmentation, confusion, many deficiencies. 1995 MDS 2.0 Raises
the Bar Care plan content expectations have Assessment process
formalized. increasing demanding. i.e. goal Increased expectations
in terms of measurability. documentation and care delivery. RAPS
about paper not process. Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 4
5. 9/22/2010 1987 to September 30, 2010 October 1, 2010 MDS 2.0
promoted inter- disciplinary care planning. MDS 3.0 promotes
resident Quality Indicators and driven care planning. Measures
created benchmarks CAAs demand looking for outcomes. beyond the
obvious. RAPs provided insurance CAAs demand staying that at least
the obvious was current with best practices. care planned. Quality
of care is the norm. Clinical assessment skills Quality of Life
comes to the were maturing. forefront. Quality of care was the
expected norm. HUGE paradigm and culture change shifts further Care
plans became more advances the human resident specific. condition.
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com 2010 Quality of Care
Actualized Quality of Life Comes to Forefront Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com Terms for Care Planning RAI MDS PCP CATs
Critical thinking Multidisciplinary CAAs Interdisciplinary CPGs
Transdisciplinary EBPs SOP Decision Trees Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 5
6. 9/22/2010 Terminology RAI Resident Assessment Instrument MDS
Minimum Data Set CATs Clinical Assessment Triggers CAAs Clinical
Assessment Areas EBPs Evidenced Based Practices CPGs Clinical
Practice Guidelines SOP Standards of Practice PCP Person Centered
Planning Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Purpose of
Clinical Assessment Areas CAAs Identify and clarify areas of
concern from CATs. Promote identification of underlying cause(s),
risks, complications. Consider fixability factors. Establish
correlations among multiple triggered CATs. Demands critical
thinking skills. Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com RAP CAA
Possible problems in 18 Possible problems in 20 care areas. care
areas. Triggers alert to possible Triggers alert to possible issues
in care needs. issues in the care needs. Triggered care area must
Triggered care area must be thoroughly assessed. be thoroughly
assessed. Documentation must meet Documentation must meet criteria.
criteria. RAPS must be the tool There is no mandated used for
conducting specific tool for the assessment. assessment. Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl &
Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 6
7. 9/22/2010 CAA Resources RAI Expert Resources In-Facility
Care plan MDS 3.0 tools CPGs Policy Baseline BIMS EBPs A general
plan to Review and CPS guide decisions PHQ-9 SOP revisions Chapter
4 Decision trees SMART goals Process steps 4-9 Care paths Procedure
& Timelines POC focus 4-12 protocols Resident Journals, etc. 20
CAAs 4-17 Fixed, step-by- preferences Appendix C step sequence CAA
resources QIOs activities or course of action Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com CAA Completion Psychosocial Well Being Debbie
Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com CAA Demands Coming off
of auto pilot. Problem solving in addition to problem management.
Assessment and Care Planning Policies and Procedures. Staying up to
date on changing practices. Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 7
8. 9/22/2010 CPGs Clinical Practice Guidelines Guidelines
developed to help health care professionals and patients make
decisions about screening, prevention, or treatment of a specific
health condition. Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com EBPs Evidence
Based Practices 1. Conscientious decision-making based not only on
the available evidence but also on patient characteristics,
situations, and preferences. 2. Recognizes that care is
individualized and ever changing and involves uncertainties and
probabilities. 3. A philosophical approach that is in opposition to
rules of thumb, folklore, and tradition. Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com SOP Standard of Practice A diagnostic and
treatment process that a clinician should follow for a certain type
of patient, illness, or clinical circumstance. That standard will
follow guidelines and protocols that experts would agree with as
most appropriate, also called "best practice." Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 8
9. 9/22/2010 Decision Tree Used in determining the optimum
course of action, in situations having several possible
alternatives with uncertain outcomes Debbie Ohl & Associates
LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com Dont get bogged down! EBP, CPG, Care paths,
etc. Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Give me a break! 15
minutesDebbie Ohl & Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 9
10. 9/22/2010 Terminology Countdown RAI Resident Assessment
Instrument MDS Minimum Data Set CATs Clinical Assessment Triggers
CAAs Clinical Assessment Areas EBPs Evidenced Based Practices CPGs
Clinical Practice Guidelines SOPs Standards of practice PCP Person
Centered Planning CT Critical Thinking Debbie Ohl & Associates
LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com How does person centered care differ from
resident centered care? Debbie Ohl & Associates LTC Consultants
& Educators MDSCarePlanBuilder.com ThinkTheThoughts.com The
identification and evaluation of evidence to guide decision making.
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl &
Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 10
11. 9/22/2010 Critical Thinking 1. Gathers and assesses
relevant information. Raises questions and problems States them
clearly and precisely Comes to well-reasoned conclusions and
solutions testing them against relevant criteria and standards; 2.
Thinks open-mindedly within alternative systems of thought,
recognizing and assessing: if, then 3. Communicates effectively
with others in figuring out solutions to complex problems without
being unduly influenced by others thinking on the topic. Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Your Job To interpret
and address the Care Areas identified by the CATs and develop an
individualized care plan that keeps the person at the center of all
activities. Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Summarize
your learning Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl
& Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 11
12. 9/22/2010 Lunch Time Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com Care Planning Teams Team A group of people
with a common purpose Discipline Relating to a particular field of
study Multidisciplinary Many Interdisciplinary Between and among
Transdisciplinary Strategy that crosses many disciplinary
boundaries to create a holistic approach Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 12
13. 9/22/2010 Care Area Assessments Promotes identification of
cause and effect relationships, contributing and complicating
factors and risk identification Correlates triggering relationships
and implications among multiple triggered CATs. Advances
recognition of resident strengths, preferences, wishes. Considers
correctability. Requires Logical Care Plan Linkage Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com CAA Review 1. Identify relevant triggers. 2.
Identify type of trigger. 3. Identify the possible causes,
contributing factors, and risk factors . 4. Analyzing and draw
conclusions. 5. Develop a personalized, resident-specific care plan
based directly on conclusions including insight of IDT members,
resident, significant others. 38 Tools, Tips & Clarifications
for Care Planning BIMS CPS MMSE PHQ-9 Issue Problem Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl &
Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 13
14. 9/22/2010 BIMS Brief Interview for Mental CPS Status
Cognitive Performance Scale Interview process used to test used in
RUGs III to the residents memory evaluate the level of cognitive o
Repetition of 3 words impairment o Orientation o Recall Residents
must be capable of MMSE responding. Mini Mental Status Exam If
resident rarely/never questionnaire used to screen understands
staff assesses for cognitive impairment. resident based on their
observations. Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com PHQ9 Resident
Mood Interview Residents must be Patient Health capable of
responding. Questionnaire with Staff PHQ if 3 or more 9 questions
items not completed by resident. Looking for signs of depression
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com ISSUE PROBLEM About
About yesterday and tomorrow. here and now. Grey area, Black and
white, intangible. tangible. Typically not solvable. Something can
be done. Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl
& Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 14
15. 9/22/2010 10 Care Plan Must Haves Debbie Ohl &
Associates LTC Consultants & Educators MDSCare PlanBuilder.com
ThinkTheThoughts.com Six general care planning areas 1. Functional
Status 2. Rehabilitation/Restorative Nursing 3. Health Maintenance
4. Medications 5. Daily Care Needs 6. Discharge Potential Debbie
Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Priority Plans 1.
Unstable health conditions. 6. Wounds, pressure ulcers. 2. Pain
management. 7. Medicare RUGs (reason for 3. New areas of risk:
falls, skin, coverage) skilling services. dehydration, etc. 4. New
problems requiring use of 8. Acute problems psychoactive medication
to * Falls correct or control. * New pressure sores * Unplanned
weight loss 5. Medications with high risk for * Unplanned weight
gain side effects, or adverse drug * Elopement reactions. *
Resident to resident abuse, * UTIs * URIs * Other Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 15
16. 9/22/2010 Components of the Care Plan Care Plan Statement 7
1 6 2 5 3 4 Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Plan
Guidance Resident Input Problem / Need Goal (s) Interventions
Responsibilities Review Dates Strength Related Approaches &
Places Scope, Severity, Linked Clear Oversight Stability Measurable
Concise Delivery Nurses Notes CAA Reasonable Do-able Progress notes
Do-able Done IDT notes Content Fix ability Use the 4 Delivery means
Review Date Contains Quadrant insuring based on SSS Fix it
consistent Improve it What physically implementation Interim Issue
Reason Maintain it mentally socially Or Control it emotionally?
Oversight Impact 4 Quadrants Expected to be Slow the decline means
Risk met Minimize/prevent Ask each monitoring for Strengths
complications discipline: what effectiveness Resident Input can you
offer What does the resident want?? 3. Developing Goals Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl &
Associates LTC Consultants &Educators
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17. 9/22/2010 2. Resident Voice Debbie Ohl & Associates LTC
Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com 4. Target Dates Meet Goal or Check Progress
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Consider the Scope,
Severity, and Stability Scope Severity Stability Pervasiveness of
the Seriousness of the problem. Current status of the problem.
problem. Present continuously (3) Immediate jeopardy to health To
what degree is the Intermittent, patterned (2) & safety of self
or others (4) problem solved Sporadic (1) Harm present or eminent
(3) and or what is the Potential for harm (2) likelihood of Minor
(1) reoccurrence if interventions are withdrawn? Debbie Ohl &
Associates LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants
&Educators MDSCarePlanBuilder.comThinkTheThoughts.com 17
19. 9/22/2010 Care Plan Formats Common Plan I Plan PGI Reads
like a book Or Changes language content of common plan Debbie Ohl
& Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com I care plan samples
I-Format Care Plans http://paculturechangecoalition.org SKIN: I am
at risk for skin breakdown because of my decreased mobility. I had
an open area on my coccyx, which I obtained while in the hospital.
It has improved to just a reddened area. I want to keep healing.
Assist me to reposition every two hours if I have not done so on my
own. Remind me to keep off my back as much as possible when I am in
bed. I have a special pressure-reducing cushion on my chair, which
needs to be straightened, before I sit in it every morning. My bed
has a pressure-reducing mattress. I take a multivitamin to help
with skin healing. I concentrate on making sure I eat proteins at
every meal. Remind me that protein will help in healing. GOAL: I
wish to remain free of skin breakdown. Debbie Ohl & Associates
LTC Consultants & Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com COMMUNICATION/MEMORY: I used to communicate
well and enjoy a hearty conversation. Humor has always been a part
of my communication style. I have become much weaker as my health
has declined. Sometimes I find it hard to even to answer I am
tired. Occasionally I have episodes of confusion. Sometimes I do
not know where I am and I become frightened. Please provide
orientation during these times and when you are providing my care.
Let me know who you are and what you are going to be doing. I
usually recognize my children and my spouse. Holding m y wifes hand
comforts me. When I am confused and frightened, I may strike out at
you. Use calm gentle touch and hand massage while providing me
reassurance. *GOAL: I dont want my memory loss and confusion to
interfere with my ability to accept the care I need. I do not want
to hurt my caregivers Debbie Ohl & Associates LTC Consultants
& Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie
Ohl & Associates LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 19
20. 9/22/2010 Comfort (Rhode Island Quality Partners) I take
regular medication for pain. Sometimes I need extra boost of
medication. I also benefit from stretching so I like to attend the
morning exercise group. The massage therapist seems me every Friday
for an hour. Massage makes all the difference. Goal: To be free
from breakthrough pain in my back Sleep medication prn. Discourage
napping during the day. Side rails up. IF unable to sleep place in
Geri-chair. I softer Plan IF I am walking at night please offer to
walk I like to walk with me. during the night. Place sashes in
doorways of resident rooms who are disturbed by my presence at
nite. Offer me snacks. I like to read the sports section of the
paper and play solitaire. Taken from web site on I care plans
Debbie Ohl & Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com Care Plan with Pain as
the Root Problem Components of Pain Care Plan: Analgesia, Quality
of Life, Ability to Function PROBLEM/NEED GOAL(S) APPROACHES/ Resp.
REVIEW Discip /STRENGTH What does the INTERVENTIO Date resident
want? NS Issue: Issue: why pain 1. Resolve and Medication plan
eliminate the Description of pain: Who can do issue if possible
type, source, location, What intensity 2. Pain Relief / When
Control Where Resulting in/ How often. creating/impacting: affect
3. Quality of on functional status Life, - What PMS/E: can you make
better? Risks / complication - What is the (think about from pain
best you can and med used) expect? Resident Strengths/Wishes:Debbie
Ohl & Associates LTC Consultants &Educators
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21. 9/22/2010 7. Review and Revision Target dates outside of
facility established reviews. Who does it? Where will it be
documented? What if the plan is off track? Care conference
scheduled reviews. Overview Status of goals Met Unmet Rationale New
areas of concern Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Assessment of
Care Plan Activities 1. Acute problems are addressed 9. The IDT
work together? timely. 10. Some team members write their own 2.
Care plans geared to preventing care plans for fear they will
avoidable declines? otherwise be cited? 3. Care plans consistently
manage 11. Documentation reflects status resident risk factors in a
timely and/or rationale on each care plan manner? goal? 4. Care
plans recognize and build 12. Direct care staff on all shifts and
on resident strengths? units are informed about the care 5. Goals
measurable? plan goals and interventions? 6. Goals achievable? 13.
The direct care staff can explain what the goals are and why they
are 7. Goals met ? doing what they are do? Person Centered Care
Planning W hat do w e live for, if it is not to m ake life less
difficult for each other? George EliotDebbie Ohl & Associates
LTC Consultants &Educators
MDSCarePlanBuilder.comThinkTheThoughts.com 21