CARE PLANNINGFOUNDATIONS FOR SUCCESSFUL DOCUMENTATION

Presented by: Vanessa Emm BA, ACC/EDU, AC-BC, CDP

TaggEmm Consulting www.taggemmactivityservices.org

MEPAP Instructor emm_vanessa@yahoo.com

NAAP Vice President naap.vanessa@gmail.com

1

Care Plans

A means of

communication

throughout the

care center. The

“Lighthouse” of

documents.

2

QUALITY USE OF LEISURE TIME OR FREE TIME

Community based recreation and leisure education

resources. What’s available in your community?

What isn’t available in your community?

Independent, individual leisure options and choice

based on stated preferences.

Volunteer therapeutic work programs both within

and outside the facility if applicable.

Problem areas.

3

SOCIALIZATION AND MEANINGFUL INTERACTION

Informal social interaction. How does this resident

socialize with others to include staff, residents and

volunteers.

Structured group interaction. Passive, active,

observer?

One-to-one interaction. Body language,

preferences.

Community interaction opportunities. Again, what is

and is not available in your community?

4

PARTICIPATION AND ENHANCED MOTIVATION

Rekindling past interest and hobbies.

Soliciting resident preferences and choices than

integrating this information into the care center’s

structured programs. This would also include

developing and implementing new programs to

meet the needs.

Special interest programs.

Resident autonomy through decision making within

various committees and resident council

5

FIRST LOOK

Assessment

The resident assessment should include but not be limited to:

a.) Mood

b.) Social History

c.) Leisure routines and preferences

d.) MDS 3.0

e.) Observations

f.) Areas of Concern

g.) Discharge Planning

h.) Therapy

i.) Diagnosis

j.) Physical Conditions

k.) Cognition Level

l.) Medical Chart (physician’s orders, nursing notes, H&P, Social

Services)

6

MDS 3.0 ASSESSMENT SECTION F

The intent of items in this section is to obtain

information regarding the resident’s preferences for

his or her daily routine and activities and the

importance level of these preferences.

This is best accomplished when the information is

obtained directly from the resident or through family

or significant other, or staff interviews if the resident

cannot report preferences.

7

BUILDING YOUR CARE PLAN

After you have completed your full activity

assessment and MDS 3.0 interview it’s time to begin

building the residents care plan to properly meet their

individual needs and preferences.

8

STEP 1

Preference, Strength, Need, Concern, or Problem

This area should include descriptions: any specific activity

preferences or daily routines that were noted and/or observed during

the assessment. Are there any factors that may affect their level of

participation or engagement in activities either group or independent.

What do they need for activity pursuits?

Accommodations?

Assistance?

Adaptations?

Therapy Schedule?

MDS Codes

Family Involvement?

9

STEP 1 EXAMPLE 1Mrs. Smith was admitted for physical therapy following a left hip fracture. Mrs. Smith anticipates a short term stay, planning to return home to live with her daughter and son-in-law. During her initial assessment Mrs. Smith was relaxed, talkative, and pleasant with staff. Mrs. Smith stated that she isn’t interested at this time in attending group programming that is offered by the care center and also declined 1:1 activity visits stating she is content with her independent daily routines. Mrs. Smith stated various independent activity routines including but not limited to: crossword puzzles, talking with friends and family on the phone, having company (daily), TV (news, All my Children, Dr. Phil, The Price is Right), and reading (mysteries, biographies, newspaper). During the MDS 3.0 interview Mrs. Smith identified the following as “Very Important”: to have reading materials available, to use the phone in private, to participate in religious services & practices, and to be outside when the weather is good. Mrs. Smith stated that she’s never been overly social in group settings “I’ve never been much of a joiner”. Mrs. Smith’s family visit daily. Mrs. Smith is very focused on her therapy schedule and returning home as soon as possible.

10

STEP 1 EXAMPLE 2

Mr. Doe was admitted to the care center with no current plans for

discharge. During the initial interview Mr. Doe displayed some difficultly

when recalling some social history questions but was able to talk

accurately about his life shortly before his admission, he was pleasant

and interactive with staff. . Mr. Doe was living in his home alone prior to

admission. Mr. Doe stated various activity interests including: poker,

TV (basketball, baseball and football games, news), social events,

fitness programs, and reading (newspaper, magazines). During the

MDS 3.0 interview Mr. Doe identified the following as “Very Important”:

to go outside when the weather is good, to participate in his favorite

activities, to be around animals such as pets, and to have magazines

and the newspaper available. Mr. Doe reviewed the activity calendar

with staff. Mr. Doe stated he would like to be active daily and requested

reminders and assistance to and from programs of his choosing. Mr.

Doe has a dx of CHF and may display fatigue and require additional

assistance. Mr. Doe’s family don’t live locally and won’t be able to visit

regularly. 11

STEP 2

Goal/Objective

1. What will the resident do?

2. How will the resident respond?

3. By When? (using a date)

4. What type of activities are targeted: large group, small group, one-

on-one, independent.

IS THE GOAL:

• Reasonable for resident

• Attainable for resident

• Observable by staff

• Individualized to residents specific needs and preferences

12

STEP 2 EXAMPLE 1

Mrs. Smith will participate and express satisfaction

AEB verbalization to staff in chosen independent/self

directed leisure pursuits such as: crossword puzzles,

TV programs, and reading as desired by 1/1/2012.

Resident’s name is stated (Mrs. Smith)

Will/Respond how (Stated satisfaction to staff)

What type of activity (Independent/Self directed, crossword puzzles, TV, and reading)

How often (as desired)

By (1/1/2012) 13

STEP 2 EXAMPLE 2

Mr. Doe will choose and actively participate in programs of choice (i.e. men’s club, fitness, outdoor activities, outings, parties and special events) minimum of once daily before his next review 1/1/2012.

Resident’s name is stated (Mr. Smith)

Will/Respond how (Choose and actively participate in)

What type of activity (Men’s club, fitness, outdoor activities, outings, parties, special events)

How often (daily)

By (1/1/2012)14

STEP 2 – COMMON MISTAKES

Resident goals can be written in error as staff goals.

AVOID:

“Staff will assist

“Staff will provide”

“Staff will provide verbal cues”

Anything that deals with staff and what staff will do

and provide is an intervention/approach and should

be documented accurately. 15

STEP 3

Approaches/Interventions

1. Use words such as: encourage, positive motivation, provide,

remind.

2. This section needs to state everything staff will do and provide for

the resident:

• Accommodations

• Modifications

• Limitations (i.e. wheelchair, HOH, vision impairment)

• Independent supplies/materials

• MDS 3.0 interventions

• Past interests

• Approaches must coordinate with the goal, problem/strength/need

• Staff are accountable for all stated approaches in the care plan

16

STEP 3 CONT. – SPECIFIC, SPECIFIC, SPECIFIC

All interventions/approaches should be individualized, specific and detailed to each resident:

→ is the resident receiving 1:1 activities/interventions? If so there needs to be detailed approaches stating what are the preferred 1:1’s and what staff are doing during 1:1’s with the resident.

→ does the resident like to read? If so there needs to be detailed approaches including preferred reading materials, genres, etc.

→ all MDS “Very Important & Somewhat Important” codes needs to have coordinating approaches.

All areas of the care plan need to have specific individualized interventions to ensure quality of life. 17

STEP 3 EXAMPLES

1. Staff will offer and provide reading materials of interest (westerns,

mysteries, newspaper, engineering magazines) as needed.

2. During 1:1 visits activity staff provide the newspaper and read

current events and the sports section to [name] as these are his

preferred areas of the newspaper.

3. Staff will invite, encourage and assist [name] outside on the patio

when the weather is good and upon request.

4. [name] currently doesn’t have a TV in his room but his preferred

activity is watching TV. Staff will invite and encourage him to use

the activity room/day room TV for sporting events and the evening

news daily until his TV arrives.

5. [name] is HOH but hears best in her left ear. During activities

[name] needs to be seated near the facilitator with the facilitator

seated on residents left side. For larger group programs [name]

will be provided with a hearing amplifier. 18

GETTING THE WORD OUT

How are you certain that your staff know what

interventions you have planned:

1. Copies of each residents care plan kept in the

activity office.

2. Copies of each residents care plan kept with the

daily participation logs for quick and easy

reference.

3. Care plan notice form filled out each time a new

care plan is developed or revised/updated.

19

MDS CAT’S & CARE PLANNING MOOD SECTION

Four of the seven triggers in the Psychosocial Well-

Being CAT’s are directly linked to activity

preferences. Here are two from the Mood Section:

1. The resident indicated they have little interest or

pleasure in doing things as indicated by D0200A1

2. The staff assessment indicated that the resident

has little interest or pleasure in doing things as

indicated by: D0500A1

The activity staff are responsible for obtaining this

information from Social Services to address any

concerns in the resident care plan and IDT meetings. 20

MDS CAT’S & CARE PLANNING ACTIVITY

PREFERENCE SECTION

Here are two from the Activity Preference Section:

1. Residents responding that it is “Not important at

all” or “Not very important” to participate in favorite

activities. Indicated in F0500F

2. During the staff assessment there wasn’t an

indication that the resident prefers participating in

favorite activities. Indicated in F0800Q

The activity staff are responsible for correctly coding

“Participating in favorite activities” for the resident.

21

COMMON MISTAKE RE: FAVORITE ACTIVITIES

Many times “Favorite Activities” are considered to

be planned scheduled group or 1:1 programs.

Keep in mind that “Favorite Activities” are whatever

the resident deems as preferred programming:

1. TV

2. Reading

3. Self-directed/independent activities

4. Outings/Activities with family/friends

It’s important that these are care planned specifically

and appropriately. 22

THE MDS IS YOUR TOOL FOR A

SUCCESSFUL RESIDENT CENTERED CARE

PLAN

23

MRS. SMITH STEP 1/EXAMPLE 1 – CARE

PLAN WALK THROUGH

Mrs. Smith was admitted for physical therapy following a left hip fracture. Mrs.

Smith anticipates a short term stay, planning to return home to live with her

daughter and son-in-law. During her initial assessment Mrs. Smith was relaxed,

talkative, and pleasant with staff. Mrs. Smith stated that she isn’t interested at

this time in attending group programming that is offered by the care center and

also declined 1:1 activity visits stating she is content with her independent daily

routines. Mrs. Smith stated various independent activity routines including but

not limited to: crossword puzzles, talking with friends and family on the phone,

having company (daily), TV (news, All my Children, Dr. Phil, The Price is Right),

and reading (mysteries, biographies, newspaper). During the MDS 3.0 interview

Mrs. Smith identified the following as “Very Important”: to have reading materials

available, to use the phone in private, to participate in religious services &

practices, and to be outside when the weather is good. Mrs. Smith stated that

she’s never been overly social in group settings “I’ve never been much of a

joiner”. Mrs. Smith’s family visit daily. Mrs. Smith is very focused on her therapy

schedule and returning home as soon as possible.

Problem, Strength, Need,

Concern or Problem

24

Goal/Objective

Mrs. Smith will remain satisfied with her daily chosen activity/leisure

routines as evidence by verbalization to staff and will request supplies for

self-directed activities as needed by 1/12/2012

25

Approaches/Interventions

1. Staff will respect Mrs. Smith’s right to refuse

activity participation and chosen activity routines.

2. Activity staff will briefly visit with Mrs. Smith during

rounds and assess for any in room activity supplies

such as: crossword puzzles, mystery and biography books, the

newspaper and religious reading materials (Bible, devotions).

3. Activity staff will invite and provide assistance as needed to the outdoor

sitting areas.

4. Mrs. Smith requested and was provided the care center’s cable

channel listing. Mrs. Smith doesn’t want to miss her favorite programs.

5. Mrs. Smith has stated that she “have never been much of a joiner” and

doesn’t want to feel pressured from staff to participate in programming or

be incessantly invited and reminded of activity programs.

26

Problem, Strength, Need, Concern or

Problem

Mr. Doe

Mr. Doe was admitted to this care center with no current

plans for discharge. Mr. Doe has a diagnosis of dementia

with behavior disturbances and a history of wandering with

some exit seeking. Mr. Doe has displayed some confusion/

frustration when asked several direct questions in a row. Mr.

Doe has also displayed some difficultly with adjusting to his

new settings in the care center, prior to his admission he was

living in his home with family (daughter Julie). Mr. Doe stated

various activity interests including but not limited to: gardening, watching

sports on TV, reading the newspaper, looking through farming magazines,

activities that provide snacks and refreshments. During the MDS 3.0 Mr.

Doe identified the following as important: being around animals such as

pets (Mr. Doe’s daughter had a dog at home named Scooby that he loves

dearly), participating in his favorite activities, participating in religious

services and practices, and doing things with groups of people. Mr. Does

daughter visits regularly (2-3x a week). Mr. Doe was a garlic/onion farmer

for most of his life and can relate and enjoy talking about farming. Due to

Mr. Doe’s diagnosis and displayed confusion/frustration he will benefit

verbal cues and reminders regarding programs and additional staff

assistance during activities.

27

Goal/Objectives

Mr. Doe will choose and attend a program of interest

minimum of once daily and remain in the program for the

duration of the activity without showing signs of frustration

By 1/1/2012

28

Approaches/Interventions

1. Respect Mr. Does right to refuse activity participation.

2. Mr. Doe will receive pet visits weekly and family will be

encouraged to bring in Scooby for regular visits.

3. Activity staff will provide a newspaper daily and farming

magazines.

4. Activity staff will remind, invite and assist Mr. Doe to

programs of choice and preference (gardening, sports on TV,

and programs that offer snacks & refreshments (happy hour, birthday parties,

special events, cooking club).

5. During activities staff will provide one-on-one directions and supervision along

with positive praise for all Mr. Does attempts during activities.

6. Activity staff will monitor Mr. Doe during programs for exit seeking and/or

wandering and will report any incidents to nursing staff.

7. Activity staff will provide positive redirection when signs of frustration occur.

Beneficial interventions include talking about Scooby, farming, asking for

assistance with the care center’s garden, tips on gardening, family and sporting

events. If interventions aren’t successful assist Mr. Doe to a calmer environment

and attempt interventions again in a one-on-one setting.

8. Allow Mr. Doe time to respond. Do not ask numerous questions in a row as this

has shown to frustrate Mr. Doe.

9. Mr. Doe is Catholic and would like to receive weekly communion. Activity staff

have contacted the Catholic Church and made the appropriate arrangements.

10. The activity department will provide garlic & onion sacks to use for positive

reminiscing with Mr. Doe.

29

“I” CARE PLANS

“I” care plans are a different format for writing a

care plan. “I” care plans can be just as specific,

individualized and appropriate for a resident.

Example

“My name is Ann. I really enjoy being social and active. While I’ve been in LTC I have had the opportunity to meet a lot of new people and try some

new things.”

“I need some reminders and assistance to and from the activities that I enjoy such as: parties, special programs and bingo. I would like to attend these programs each

time they are offered.” 30

KEY TO SUCCESSFUL CARE PLANS

Quality assessments, intakes, and documentation.

Samples provided include:

1. Annual Assessment

2. Initial/Re-Admission Assessment

3. Significant Change Assessment

4. Quarterly Review Assessment

5. Initial/Reassessment Intake Form

6. Blank Care Plan Form

7. Individual Resident Activities Form

8. Activity Evaluation Form

9. Overall Activity Plan31

A Care Plan is your

CANVAS

It is up to YOU to

paint the accurate

picture for your

residents

32

Assessment/

History

MDS 3.0

Preference, Strength, Need,

Concern, or Problem

Goal/Objectives

Approaches/

Interventions Resident

Centered

Activity Care Plan

33

HELPFUL FOR REVIEWING CARE PLANS

Review activity participation logs/MDS

Review 1:1 documentation

Review previous progress notes

Resident interview/review of current care plan

Staff interviews

34

WHEN WRITING A CARE PLAN KEEP THIS IN MIND

What’s important to me?

What would I want people to know about me?

What would my expectations be?

What should I expect?

What if my voice isn’t heard?

Will people understand me?

Will I be HAPPY?

35

QUESTIONS?36