Chapter 21 Federal Regulations

Care Process (NCP) for documentation of the assess- ment and nutrition diagnosis. This information may be located in a separate nutrition/dietary section of the resident’s paper chart, may be a separate compo- nent within the electronic medical record, or may be maintained in the same location as all the other CAA assessments.

The CAAs are required for all OBRA compre-

hensive assessments: Admission, Annual, and Significant Change in Status or Significant Correction of a Prior Comprehensive. The CAA is to be completed within the same time frame as the MDS.

In OBRA regulation 42 CFR 483.75 (i), the medical director is identified as being responsible for “overseeing the implementation of resident care policies and the coordination of medical care in the facility” (4). Collaboration between the medical direc- tor and the IDT members to identify evidence-based resources and standards of practice to be used in further assessment and analyses of triggered areas is critical in the CAA process. The resources used should be available upon request during the survey process.

INTERDISCIPLINARY CARE PLAN OBRA regulation CFR 483.25 directs the IDT to use the comprehensive care plan as a communication tool. The care plan identifies measurable objectives and time frames and describes the services that should be provided in order to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being. Services that are provided to the resident need to be consistent with the care plan, and the care plan must be reviewed and revised based on the needs of the resident (8). With that in mind, the development of an effec- tive nutrition plan of care for a resident requires the RDN to be cognizant of all aspects of the resident’s physiological, psychological, and sociological status. The MDS data, the CAAs, and a comprehensive nutri- tion assessment are used to design a care plan that is individualized for each resident. It is important to include residents or their designees in the nutrition care planning process in order to meet their needs and to assist in improving their nutritional status. The inclusion of residents is critical in making sure their resident rights are being maintained and they are pro- vided different choices as to how they want their care to be provided. A plan of care for the resident begins on the first day of admission to the facility. Facilities use an “interim care plan” until a comprehensive care plan has been developed. The facility has up to 14 days to complete the MDS and an additional 7 days to

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complete the comprehensive care plan. Remember, the necessary care and services for each resident must begin upon entry into the facility. The interim care plan is developed based on hospital transfer information, the initial nursing assessment, and any information provided by the resident or designee. It is important for the RDN to have systems in place for residents who come into the facility at nutrition risk in order for them to receive nutrition support, if needed, until the full nutrition assessment can be completed and individualized needs are identified. Waiting until the RDN assesses the resident to start interventions could be identified as failed practices for a resident in need of nutrition care immediately upon entrance into the facility. The assessment process is necessary to identify problems and help in decision-making as the plan is developed. The CAA process is the link between the MDS and the care plan. Using the NCP for the assessment and to deter- mine the interventions and care plan for the resident will meet the needs of the resident and regulatory requirements. The NCP is not mandated, so other assessment processes can be used within the federal guidelines, but use of the NCP is strongly encour- aged by the Academy of Nutrition and Dietetics. Care plans are implemented in all areas along the health care continuum and allow for an integrated approach involving the resident, facility staff, the resi- dent’s family or guardian, and the physician. See Table 21.6 (see page 323) for the clinical problem-solving and decision-making process and objectives identified in the RAI manual.

The goal of care planning is to develop a course of action designed to maintain or return the resident to the best possible state of health. In the develop- ment of the care plan, the resident should be viewed as a whole human being with unique characteristics and should have input into the process and goals. The RDN develops the nutrition component using the interdisciplinary format identified by the facility. The NCP for development of the care plan will usually fit within a facility-designated process. The RAI manual does not dictate a specific format for the care plan. In general, each resident’s care plan should have the following (8):

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Problems or needs that must be addressed to attain and maintain the resident at the highest practicable physical, mental, and psychosocial well-being. Care plans can also identify the resi- dent’s strengths.

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Realistic and measurable goals. Must be stated in terms of expected behaviors, must be changed as the resident’s condition changes, must have an