Care plan conferences play an important role in risk management

Care plan conferences are not only a time to discuss the current plan of care for the resident, but they are also a time to disclose to the resident and family members other pertinent resident information which pose high risk and potential litigation concerns.

The facility should encourage the resident and family to participate in the care plan conference. Care plan conferences could last between 1- 3 hours, depending upon the acuity of the resident. The more informed of the care and services being offered, the more educated the resident and family representatives will be, and therefore, will be able to make informed decisions regarding the resident’s care needs and potential risks associated with the resident’s disease processes, cognitive status, and lifestyle preferences.

If the family representative is unable to attend the care plan conference in person, find out if they could do a conference call with the care plan team. Should they decline the conference call, the care plan team should provide the family a written summary of the information discussed at the care plan conference via mail/e-mail. With families who may be more challenging, the care plan team may choose to mail the care plan summary as certified mail so there is documentation the resident representative received the mailed summary.

During the conference, it is very important to discuss the resident’s medical diagnosis, inform the family of the current symptoms for the disease/diagnosis, and explain what the future potential negative outcomes of the disease/diagnosis will be. The internet has several family-oriented disease education pamphlets available for anyone to download. The care plan coordinator can print two copies -- one for the resident/family representative and the other for the facility to put in the resident chart as resident education in the care plan section. Though the resident/family representative may say they know what to expect with the disease, providing information and educating them on the disease process shows the resident and family the critical thinking that the care plan team utilized in developing the resident’s individualized care plan.

Providing information and education should also be done when the resident is non-compliant or chooses not to follow the recommendations or physician’s orders for the disease process. By educating the resident and family of the potential negative outcomes of non-compliance and the alternatives offered to the resident, the facility meets the regulatory intent of educating the family on what the potential negative outcomes can be with the resident’s non-participation of physician orders and/or cares. As non-compliance issues arise, the care plan team may need to have another care plan conference with the resident/family representative. Care plan conferences must be held quarterly per the federal guidelines; however, they can be held more often if the facility and care plan team deem necessary.

The care plan conference is not only a time for the care plan team to talk about the resident’s disease processes and the care and services being provided to the resident, but also a time to ensure the care plan team is gathering information from the resident and family representative. The care plan team should be prepared to be able to address other potential issues, concerns, or questions such as:

• What a care plan conference is, how often is it held, and what will be talked about at each conference?
• Who should the resident/family representative contact if they have a specific question they need to have answered before the next care plan conference?
• Have there been any changes in the health/behavioral status of the resident since admission or last conference? If so, explain why in simple terms. Disclose if these events will improve, be permanent or deteriorate.
• Have there been any adverse events or occurrences that have taken place, i.e., falls, pressure ulcer or behavioral outbursts? What was the root cause? Disclose if these events will be able to be prevented, reduced, or will continue to occur due to resident disease process and cognitive status.
• Has the resident been seen by any physicians, and if so, what was the outcome from the visit?
• Has the resident had issues with their vision or teeth?
• Have there been any recent labs drawn and the results?
• Have there been any medication changes since admission or the last conference?
• What is the status of any special therapies that are or have been provided?
• How is the resident eating (percentage of meal intake)? Have they lost or gained weight?
• How is the resident and family adjusting to the nursing home placement?
• How often the resident is participating in activities or social events?
• Any changes in the resident’s living will, or DNR status?
• Are there any items the resident may need or want with them, i.e., special photos, reading materials, electric razors, clothing, or footwear?
• Are there any changes in the facility administration, nursing administration, or other department heads and if so, what is their new contact information?
• Are there any changes in the resident representative contact information? Any preferences of how they would like to be contacted? Any time of day they do not desire to be contacted? If so, time they can be contacted?

In conclusion, by using the care plan conferences to disclose the resident’s high-risk concerns, the facility is completing an essential step in the risk management program.

References:

• Centers for Medicare and Medicaid: RAI MDS 3.0 Manual, Chapter 4 & Appendix C.
• Center for Medicare & Medicaid: Appendix PP – Guidance to Surveyors for Long Term Care-Facilities: F656 & F657 Comprehensive Care Plans.
• Centers for Medicare and Medicaid, “What’s a care plan in a nursing home?” https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-a-nursing-home
• The National Consumer Voice for Quality Long-Term Care; “Assessment and Care Planning: The Key to Quality Care”; https://theconsumervoice.org/uploads/files/issues/assessment__care_planning-final.pdf