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Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

Federal Regulation - F280 Comprrehensive Care Plans

F280 - Comprehensive Care Plans was the 9th most cited regulation as a deficiency during 2009 in long term care facilities in South Dakota. There were 18 deficiencies written for F280.  This regulation says,

483.10(d)(3) The resident has the right to -- unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State – participate in planning care and treatment or changes in care and treatment.

483.20(k)(2) A comprehensive care plan must be---(i) Developed within 7 days after the completion of the comprehensive assessment; (ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs, and, to the extent practicable, the participation of the resident, the resident’s family or the resident’s legal representative; and (iii) Periodically reviewed and revised by a team of qualified persons after each assessment.”

When becoming familiar with this regulation we need to keep in mind the whole picture and how the resident’s comprehensive care plan fits in this picture.

Prior to addressing the residents’ comprehensive care plans, the regulations address the Resident Assessment Instrument (RAI) process. The RAI includes the Minimum Data Set (MDS) and Resident Assessment Protocols (RAP)s. This process which is required for all residents is the systematic comprehensive assessment on which the resident’s comprehensive care plan is based. 

What are the key points in this regulation?

  • The resident’s right to participate in the planning of his/her care
  • The comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment
  • The comprehensive care plan must be prepared by an interdisciplinary team including the physician, registered nurse, and other disciplines
  • The comprehensive care plan must be periodically reviewed and revised by the team after each assessment

Resident’s Right to Participate

According to the Guidance to Surveyors this right is also covered in 483.20(d)(2) and 483.10(b)(4)

  • 483.20(d)(2) I was not able to find 483.20(d)(2), but I did find (d) F286 which referred to a facility maintaining all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive plan of care.
  • 483.10(b)(4) F155 which states, “The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section; “  further definitions are provided in the Guidance to Surveyors regarding “Treatment”, “Experimental Research”, “Advance Directive”.

The right to participate in planning care and treatment means the resident is provided the opportunity to choose from treatments available. The resident’s participation is required with initial decisions about the care plan and as change is needed. How do surveyors assess whether the resident is included in the care planning process? Surveyors may interview the resident or resident’s family with open-ended questions about how they are included in the care planning process. Interview of the interdisciplinary treatment team about the care planning process may also occur. Questions such as “How does your staff involve the residents and families, surrogates, and/or representatives in care planning?” may be asked of your team. Another means of assessing resident and/or family involvement in the care planning process is review of the documentation of the care planning process or meeting and the attendance record. Does your facility try to schedule care plan meetings at times when residents and their families can come? Examples of questions surveyors may ask are included in the Guidance to Surveyors. A facility quality improvement study could be developed by using some of the surveyor questions to do an audit for a sample of the residents to assess how well your facility is promoting resident participation in the care planning process.

When it comes to the resident’s right to accept or refuse treatment, something to consider is what happens when the resident demands a particular treatment that is experimental or inappropriate. This is a situation in which it is important to remember the facility is ultimately accountable for the resident’s care and safety, including clinical decisions. Clinical decisions need to be based on professional standards of practice and evidence-based practice.

Care Plan is Developed Within 7 days of Completion of the Comprehensive Assessment

This section of the regulation is clear.  Once the comprehensive assessment has been completed the interdisciplinary treatment team has a 7 day window to complete the comprehensive care plan. In order to comply with this section, it is obviously important for the treatment team to work together on a consistent basis to complete the care plan. If a team member is on medical leave, what arrangements are made to ensure the process is not delayed? This is a question that may arise from the surveyors when they detect a pattern of delays in completion of the care plans.

Care Plan is Prepared by an Interdisciplinary Team

This means the professional disciplines, as appropriate, will work together to provide the best care possible to the resident. The dynamics of how this is done is up to the discretion of the facility which means this can be accomplished by a face-to-face meeting, teleconference, or written communication such as email.  What is important is that the team collaborates and communicates with each other during this process.  When the team approach does not happen there may be inconsistencies in the goals and interventions. Nursing staff might have interventions to encourage fluids because the resident has an infection and the dietary staff may include interventions for fluid restriction due to chronic kidney disease. 

The Guidance to Surveyors stresses that the physician must participate as part of the interdisciplinary team. Some creativity may be needed due to the physician’s schedule. Conference calls may be needed or one-on-one discussions. During the survey process, assessment for evidence of the interdisciplinary team collaborating is done through interview, medical record review, and care plan review. 

Care Plan is Periodically Reviewed and Revised after each Assessment

The review and revision needs to be completed by qualified persons. Who are qualified persons? These are the professional staff licensed, certified, or registered in accordance with state laws. Based on survey experience, I found the care plans were updated when the RAI assessment was done. Problems usually arise when something occurs with the resident between assessments; perhaps a medication was discontinued and another medication prescribed, or the resident developed a urinary tract infection requiring short term need interventions. A system needs to be in place to make sure the care plan is updated appropriately. Some facilities have a short term care plan or acute care plan format which is initiated when something occurs in between time. The care of the resident must be based on the care plan. Without that driving force there is little meaning in the day to day care of the resident. We just end up providing custodial care without thought of the individual needs. Those days are long gone – thank goodness.  I remember when I was a nursing student in the late 1960s. There were two experiences I will never forget. 

  • Nursing home: It was in the fall, and we were having nice warm weather at that time. The area my student group observed was on the second floor. The first thing I noticed was the strong urine odor.  There was no air conditioning. Windows were open, but I don’t remember what kind of screens were on the windows, perhaps they were not present or in poor condition. There were so many flies landing on the residents and on their food at meal time.  The residents were sweaty and displayed no energy or interest in their surroundings. There were no care plans. This nursing home is no longer in existence.
  • State Hospital: One of the buildings on the campus housed elderly residents not able to walk anymore. There were rows and rows of beds with elderly residents in them. Privacy and dignity probably was not provided due to the physical environment. As I recall, there was a schedule for feeding, bathing, toileting, changing incontinence pads, and repositioning. Very little documentation was done, and there were no care plans for the residents. This was custodial care in an institutionalized setting.   This hospital’s geriatric program today is nothing like the description from the 1960s. Their last survey was deficiency-free!

When I get concerned about all of the regulations for our long term care facilities, I think back to my first experiences in long term care, and I am grateful for the improvements that have been made.

Survey preparation requires team work and effort. Is your team on board for a successful survey when the Department of Health arrives? Start early so your team can accomplish change; improvements require sufficient time. Contact Avera Education and Staffing Solutions at 605-668-8475 to schedule a consultation to begin preparing for your next survey.

Contact me at mapederson@avera.org for all of your Regulatory Compliance and Survey Preparation needs.

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

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.

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.

Have a question for Marci? A topic idea for her next column? Need more information on having a mock survey at your facility? Send her an email at mapederson@avera.org.