Q: We are having a large debate about care planning in our facility. Some people believe the basis of the care plan is to identify the resident’s care problems and plan actions, implement steps to care for those problems, and establish assessment dates, and then put MDS into the care plan. On the other side of the argument we have the MDS Coordinator who says that the basis of the care plan is the MDS criteria and the resident’s care plan is based upon the criteria in the MDS. Which view is more accurate?
A: The assessment information must be used (MDS plus CAAs) to develop the final care plan for a patient. Although there is merit to both sides of this argument since immediate care plans must be in place even before the first MDS is completed, the regulation is clear. I’ve included both the Ftag regulation and the information from the MDS User’s Manual.
- IOM 100-07 State Operations Manual, Appendix PP, F279, §483.20(d): (A facility must..) use the results of the assessment to develop, review and revise the resident¹s comprehensive plan of care.
- MDS 3.0 User’s Manual, PG 2-38: Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident¹s plans of care that will be used to provide services to attain or maintain the resident¹s highest practicable physical, mental, and psychosocial well-being.