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Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

Federal Regulation F279

Federal Regulation - F279 "Develop Comprehensive Care Plans"

South Dakota long-term care facilities had 19 deficiencies cited for F279 in 2010. F279 ranks number 6 in the top twenty deficiencies for long-term care in South Dakota.

Regulation F279 states, "A facility must use the results of the assessments to develop, review and resolve the resident's comprehensive plan of care. (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:

(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being as required under 482.25; and

(ii) Any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4)."

The comprehensive care plan is one part of the Resident Assessment Instrument process. First the Minimum Data Set is completed, and then CAA areas are triggered. The healthcare team must then review the CAA's, use critical thinking skills and show rationale for deciding whether to proceed with care planning. The facility must conside care plan interventions for all CAAs triggered by the MDS.

Sounds pretty simple, right? Not so much! For each resident to have a comprehensive care plan that provides services to attain or maintain the highest practicable physical, mental and psychosocial well-being requires all of the healthcare team participating in the RAI process. For the process to work, the healthcare workers who are contributing to the assessment and then developing problem statements, objectives and interventions must actually see the resident and interview the resident if the resident is cognitively able to be interviewed. There must be communication amongst the team members, including the resident providing input when he/she is able. In some facilities, team members share the completion of the MDS and review of the CAAs and then another person may be assigned to write the care plan. Sometimes, a facility may assign a nurse to write the care plan based on the MDS and CAAs. It should work in theory, but in reality this method of care planning can lose true meaning in translation. Due to time constraints, the nurse in this example did not interview or care for the residents whose care plans she composed. The care plans showed little evidence of being individualized and were very generic. The team needs to be involved throughout the whole process. This reminds me of the fable about the blind men and the elephant:

One of the versions of the story tells of six blind men who are asked by the king to determine what an elephant looks like by feeling different parts of the elephant's body. The blind man who feels a leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.

The king explains to them, "All of you are right. The reason every one of you is telling it differently is because each one of you touched a different part of the elephant. So, the elephant actually has all of the features you mentioned".

This story shows why we need the team to assess the resident and develop the resident's care plan based on the assessment. Each member of the team brings a unique perception to the table. The members of the team, along with the resident or his/her representative, must work together to develop a unique multi-dimensional individualized plan of care for each resident. Without the team, the plan of care shows only one dimension of the resident in the way the fable's one blind man perceived the elephant.

If your facility is experiencing challenges with care planning for your residents, contact AESS at 605-668-8475 for solutions.

As a former health facilities senior surveyor, Marci worked at the Department of Health Office of Licensure and Certification for eight years. Marci provides Survey Preparedness Consulting designed to create a culture of constant survey preparedness by helping staff understand regulatory requirements, not just comply with them.

Contact me at for all of your Regulatory Compliance and Survey Preparation needs.

Do the math! The facility bottom line improves when resident care continually improves.

Read more Regulations Updates. The Avera Solutions' Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.

Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.