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Part III Standards for Compliance

anticipated date of completion or attainment, and must designate responsibility.

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Interventions/approaches to solve problems and satisfy needs. These must state what is to be done and by whom for each specified problem. In describing an intervention, words such as encour- age, understand, or reassure should be avoided. Each statement should start with a verb such as provide (eg, “Provide a cup with a large handle and teach resident how to use it to reach the goal of self-feeding and drinking”). Some facilities are moving away from this type of care plan and using the “I” care plan instead. For example, the care plan would read, “I prefer to use a large-han- dled fork with my meals,” “I am no longer able to drink without using a sippy cup,” or “I require help with cutting my meat into small pieces.” Many facilities are using a one-page care plan that is truly being utilized as opposed to much longer care plans.

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Implementation that is carried out as stated in the care plan. It is essential that the timing, repeti- tions, and sequencing be followed precisely by the designated persons to ensure consistency of implementation.

● ● An evaluation/reassessment of the resident.

A discharge plan developed in accordance with facility protocol.

The care plan is part of each resident’s medical record. It must be accessible to all who are involved in the res- ident’s care, including the resident and the resident’s family or guardian. It is reviewed regularly to ensure that the approaches to improve or maintain the resi- dent’s state of health are effective. If the identified interventions are not working to maintain or improve the resident’s health, the care plan must be immedi- ately updated and revised based on the recognized current needs of the resident. In these cases, the changes can be manually written if a hard copy exists and/or updated within the electronic health record and then communicated to all those affected. The simplest terminology possible should be used in writing the care plan to ensure that all members of the team, especially the resident, understand the plan and expectations.

IMPLEMENTING THE CARE PLAN One of the most effective methods for planning resident care is the IDT conference. This offers an excellent opportunity for developing a coordinated plan for each resident. It allows each discipline to share assessments and to gain a greater understanding of the total needs of the resident. Much can be learned by carefully listening

to and questioning other team members. Team coopera- tion is particularly important because implementing the goals often involves more than one discipline. For example, when one of the goals is weight gain, the RDN develops a personalized diet plan and counsels the resident; the NDTR or dietary manager makes sure that the food is served correctly and offers support; the activities director plans activities to include the resi- dent’s favorite foods or food-related activities; the nursing staff provides support and reinforcement to the resident; and the social worker will work with the resi- dent to develop a discharge plan, if appropriate, that would include congregate meals, Meals on Wheels, and a home health aide for meal preparation, or identifying a grocery store that will deliver food.

Nursing often is the appropriate discipline to chair

the IDT conference because of frequent contact with the other disciplines. It is advisable that all the disciplines meet as a team at regularly scheduled intervals. The physician has ultimate responsibility for the health care of the resident and may be invited to the conference but generally is not asked to chair the team (8). Even if not able to attend, the physician must be provided the infor- mation developed by the IDT and document the review and approval.

Each discipline should come to the conference prepared to share assessment data. Since the confer- ence is usually prescheduled, the RDN can prepare by collecting and updating the nutrition assessment data and developing tentative plans for dealing with the problem(s) identified. After the IDT conference, the chair of the team follows with written information. Many of these items will be suggestions and recommendations made by the disciplines, including the RDN, at the conference. The nutrition care recommendations most often will be found in the progress summary of the assessment and will have been discussed during the team conference. If the RDN is unable to attend the care conference, the dietetic designee signs as a representative of the department.

The facility is ultimately responsible for the overall care of its residents, including their nutrition care. The role of the RDN is to provide a thorough nutrition assessment of the resident, identify problems and concerns, and be an active participant in the devel- opment of interventions that will be included in the care plan. These procedures ensure that recommenda- tions made by the RDN are included in the care plan if the RDN cannot attend the conference. The care-planning process is used to develop a plan of action to prevent avoidable decline, manage risk factors, and build on the resident’s strengths. Care plans are evaluated/reassessed at least every 90 days. If