CMS Phase One Regulations must be implemented by November 28, 2016. Significant changes and highlights include:
Facilities must develop and implement a baseline Comprehensive Person-Centered Care Plan for each resident within 48 hours of their admission.
A nurse aide and a member of the food and nutrition services staff must be included in the interdisciplinary team that develops the comprehensive care plan.
Facilities must develop an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program and designate at least one Infection Preventionist (IP).
Each facility must have in effect a compliance and ethics program that has established written compliance and ethics standards, policies and procedures that are capable of reducing the prospect of criminal, civil, and administrative violations.
CMS Phase One Regulations
CMS announced the new version (v1.14.1) of the MDS 3.0 is scheduled to become effective October 1, 2016.
A new section GG has been added to the MDS. These item sets are required for Medicare Part A residents at admission and discharge to establish and assess functional abilities and goals.
LTCS Books publications are now all current with the MDS v1.14.1 and with all of the latest RAI Manual updates, Surveyor Guidelines, and federal regulatory changes.
Coding Instuctions for Sections GG Functional Abilities and Goals
Nursing care plans are usually arranged into the three parts of Care Plan Problem, Care Plan Goal, and Care Plan Interventions.
Problem statements are traditionally based on a nursing diagnosis. The nursing diagnosis is a problem that nurses can identify and treat. Medical diagnoses can be part of the nursing care plan problem statement, but not the actual problem itself. The most commonly used nursing diagnoses are the ones approved by NANDA, the North American Nursing Diagnosis Association, and are grouped by functional health patterns.
The goal can be to prevent a potential problem from occurring, to maintain a present status or level of functional ability, or to resolve a currently existing problem. Goals are usually stated in terms of an action the resident will perform.
Interventions describe specific actions taken by the staff to achieve the stated goal, and are based on standards of clinical practice. Like the goals of nursing care plans , interventions need to be specific, measurable, appropriate, and realistic. Interventions are worded in terms of what the staff will do to assist the resident to meet the stated goals for the problem.
Evaluation is an ongoing activity that examines the problem itself, the goals, and the interventions to determine if they are still applicable or if changes to the care plan need to be made.
See how these principles are applied by viewing these sample care plans:
Communication Nursing Care Plan
Vision Nursing Care Plan