Are my Care Plans right? 🏡

How do I know my Client Care Plans are right?
 
Changes in a client's care plan happen. In fact, you might want a care plan to change because often times that means there is an increase in hours.

BUT, in order to be in compliance you need to make sure the CARE PLAN is updated if there is a change in services provided or frequency of visits (from 1x/week to 2x/week, etc.)

Today, let's take a look at a recent Colorado home care survey to help see what an outdated Care Plan looks like that ends up as a deficiency from survey.
 


Home Care Deficiency - Consumer Records

Date of Survey: 10/18/22
Regulation Topic: Information Management System - Consumer Records
Regulation #: Chapter 26, Section 5.15
Deficiency #: 662
 
Deficiency Text:
 
On 10/18/22, a review of Consumer #1's record revealed a start of care date of 9/16/21. Consumer #1 received personal care worker (PCW) and homemaker (HMK) services.

a) The agency failed to ensure the care plan included the frequency and services on a consumer specific basis for Consumer #1.

Review of the care plan dated 3/9/22 revealed, Consumer #1 was to receive services two days a week for three hours a day. Consumer #1 was to receive the following PCW services; skin care, assistance with ambulation, bathing, dressing, and hair care on all shifts. Consumer #1 was to receive the following HMK services; meal preparation, dishwashing, vacuuming, sweeping, mopping, trash removal, bathroom cleaning, bed making, linen changing, and laundry on all shifts.

Review of Consumer #1's timesheets, from 4/10/22 to 5/28/22, revealed the consumer received services only once per week. Further review of the timesheets revealed Consumer #1 did not receive the following PCW services; skin care, ambulation, bathing, and hair care. Further review of the timesheets revealed Consumer #1 did not receive the following HMK services; meal preparation, dishwashing, vacuuming, sweeping, mopping, and bathroom cleaning.

During an interview on 10/18/22 at 11:30 a.m., the alternate agency manager stated the agency was aware of Consumer #1 only received services once a week and only for some of the tasks that were noted on the care plan. When asked if the agency had any documentation or communication notes regarding Consumer #1 agreeing to the changes to the care plan, the alternate agency manager stated she did not. She went on to state, the agency reviewed the care plan with the consumers on a yearly basis, but did not update them when changes to the schedule or services were made.

document, document, document...

How can we fix this for your agency?

The key to this deficiency is what was documented, or not, in the client’s record. Had there been a note put in that the client wanted a change in visit frequency and updating the services provided, then there is no deficiency.
 
So, how can you avoid this deficiency? There are 2 easy steps you can take to make sure you are in compliance.
 
Step 1: Make sure you have a system for reviewing Client Care Plans and a Policy.
 
If this issue comes up during a survey, the first question from the surveyor will be, “Can I see your Consumer Record policy?” Now is a perfect time to make sure you have a policy. A comprehensive policy needs to include the following items:
  • Agency will ensure each client has a complete and accurate record
  • Record shall contain sufficient information to identify the consumer, justify the care, treatment and/or services delivered
  • Records shall contain communication with the client regarding services provided and frequency of visits
  • Updates to Care Plans can be done by creating a new Care Plan OR by documenting changes to the Care Plan in the EMR/Client Record
Also, it is important to have an audit system in place just so you can double check documentation for Care Plans. I recommend starting with 5 Clients per month. Check the Care Plan for the client to see what is stated for frequency of visits and services provided. If that doesn't match, then go into the EMR system and look for agreed upon changes.

If you don't like what you are seeing, then you'll need to identify a plan to update existing Care Plans now and an audit system for each month in the future.
 
Step 2: Provide education to your team on how you want to Care Plan changes in the client record.
 
Another step towards making sure changes to Care Plans are getting documented in the client record is to tell your team how you would like it done. One of the best ways to do this is to provide education to your staff on the process for changes in the Care Plan, including with your office staff and where they should document.
 
For field staff, the main education is that they need to contact the office immediately if a client is requesting a change in frequency of visits or services provided. The office staff would then document the change and change the schedule, etc.
 
But, most importantly, the staff needs to make a note about the changes in the record.