A new rule proposed by the Centers for Medicare & Medicaid Services (CMS) would revise the requirements that long term care facilities must meet to participate in the Medicare and Medicaid programs. CMS 3260-P Reform of Requirements for Long-Term Care Facilities was published in the Federal Register last July.
CMS contends that these changes are long overdue and are an important focus in achieving improvements in the quality of care being provided through federal programs.
Although this rule is in its proposed stage, one of the over-arching themes is a focus on a comprehensive person-centered care planning process. At the foundation of the regulation is the right of residents and their representatives to be informed, involved, and in control of decisions involving care.

What‘s The Buzz? This Isn’t New, Or Is It?

Comprehensive care planning has always been a core requirement in skilled nursing facility (SNF) regulations. Step back in time to October 1995 when Congress passed the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), otherwise known as the Federal Nursing Home Reform Law, “to ensure good clinical practice by creating a regulatory framework that recognize[s] the importance of comprehensive assessment as the foundation for planning and delivering care to the nursing home residents.”

That law gave CMS’ predecessor, the Health Care Financing Administration (HCFA), the authority to issue regulations to improve SNF patient care.

By placing emphasis on assessing, planning, and providing individualized care, HCFA (read CMS) fostered a holistic approach to resident care and strengthened team communication based on data collected in the Minimum Data Set (MDS) 1.0.

Many Revisions Later

Moving forward, since OBRA ’87, there have been many revisions to the MDS, with the most current Resident Assessment Instrument Manual 3.0 version 1.13 coming out in October 2015. However, then and now, the plan of care continues to be the first step in designing a course of action that uses residents’ individual strengths to move them toward specific goals.

Based on data collected on the MDS, the interdisciplinary team would build the care plan for review with the resident and a “responsible party.” The current time frame would allow a facility up to 21 days to develop the comprehensive care plan for a newly admitted resident in the SNF.

However, while it is believed that SNFs are developing a resident-specific plan of care much sooner than required, a February 2013 OIG report found that for 37 percent of the resident’s stay, facilities did not meet requirements for care planning (https://oig.hhs.gov/oei/reports/oei-02-09-00201.asp). Therefore, CMS is proposing to have SNFs develop an interim plan of care within the first 48 hours of admission.

So, What’s Changed, What’s Happening?

Currently, there are two source documents that outline requirements: §483.20(k) for care planning and §483.20(l) for discharge planning. CMS proposes to relocate these to §483.21 and combine all of the new requirements for care planning in one location.

This proposed revision to the regulation addresses the timing of the plan of care and who is to be involved in its development. The changes are meant to have a positive impact on the care facilities provide and, as a result, ensure that residents live with dignity, respect, and improved self-esteem and self-determination, while protecting their choices. The revisions are meant to support the residents’ involvement and control.

The regulations place increased emphasis on the resident’s right to participate in the care planning process. Additionally, the changes identify individuals, or roles, termed “other appropriate staff,” to be included in the process whenever their role would benefit the specific needs of the resident.

Other members that have been identified as required participants of the interdisciplinary team (IDT) include nurse assistants responsible for the resident’s care, members of the food and nutrition department, and social workers who provide a vital link between providing individualized quality of care and quality of life specific to each resident.
In addition, CMS recognizes the support that certified health information technology can provide to increase easy and efficient communication in the development of comprehensive care plans.

What Is CMS After?

The intent of the CMS proposed changes is to ensure the resident’s involvement, while aiming toward an increase in resident satisfaction and safety. SNFs will be required to complete a baseline interim plan of care within 48 hours of admission.

The interim plan would outline interventions that would increase resident safety and mitigate adverse events, especially those more likely to occur soon after admission, such as weight loss, dehydration, behavioral issues, and fall and elopement risk, to name a few. Also during those first 48 hours, the care planning team would need to assess the resident’s potential for future discharge and transitions in care in order to attain the highest level of quality of life.
Bottom line? The proposed revisions are intended to ensure that residents receive adequate information in a manner that they can understand and use to become an active partner in the care planning process and to advocate for their own health care needs throughout their stay and beyond.

To read more on the proposed rule, see Section II, H: Comprehensive Person-Centered Care Planning (pages 26-30), www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf.
Paola DiNatale, RN
Paola DiNatale, RN, MSN, NHA, is a senior health care specialist at PointRight. She has been with the company since 2005 as an expert in quality improvement services and clinical program development, continuing care retirement community and single SNF facility operations analysis, due diligence, long term care survey and certification process, assisted living operations improvement, and Medicare and Medicaid reimbursement. Her master’s degree is in nursing as a clinical nurse specialist in gerontology.