“These are some of the BEST books I have purchased & worth every penny! After having the time to look the MDS Coordinator’s Handbook,I am going to keep it!It is up to date, comprehensive, and one of the BEST manuals I have seen to help me do my MDS Consulting work!I can’t praise Debra Collins’ work enough!I’ll be promoting her book to my colleagues!!”

Fran Koch, RN, BSN, RAC-CT

Nursing care plans in the books and on the CDs on easy to use templates can be made resident and facility specific or converted to I-care plans for Culture Change in one click.

Diagnoses, goals, and interventions based on the language of MDS 3.0, and up to date with latest RAI Manual changes, federal regulations, and surveyor guidelines. 

Check out our new Online Inservices!

The statistics will shock you. During 1999-2001, nearly 1 in 3 U.S. nursing homes were cited for violations that had potential to cause harm or that had caused actual harm to a resident.  

Educating staff members on abuse prevention is more important than ever, and should always be part of yearly inservice training.  

UC Irvine’s Center of Excellence on Elder Abuse and Neglect has some great resources for abuse education, and is the world’s first Elder Abuse Forensic Center, bringing together physicians, psychologists, law enforcement, social workers and others to handle complex cases.  

The center hosts the Elder Abuse Training Institute which identifies the most pressing training needs in elder mistreatment, and was recently named by the U.S. Administration on Aging as the National Center on Elder Abuse.  

Download their printable brochure Abuse of Residents of Long Term Care Facilities and read detailed facts and statistics about elder abuse.  

Check out this comprehensive and affordable online inservice for Preventing Resident Abuse . 

See the full list of LTCS CNA Inservices Online. 

Surveyors will investigate if the resident declined or failed to improve relative to expectations, and determine if this was avoidable or unavoidable.

The Care Plan is a record that describes the resident’s functional abilities at different times of the past year. Make sure the documentation is comprehensive and genuinely reflects the resident’s abilities. If the goals are realistic and regularly measured, it will help to identify declines.

Surveyors will focus on the Late-loss ADLs, those considered to be the last to decline or deteriorate: Bed Mobility, Transfer, Eating, and Toilet Use. They will use the Quality Indicators and the Quality Measures, and evaluate occurrences and preventative measures.

The Admission Assessment and Care Plan should accurately document the resident’s mobility, range of motion, transfer ability, and balance. Evaluations from Physical Therapy, Occupational Therapy, and Restorative Nursing will give in-depth information about the resident’s level of functioning.

The goal in documenting the Care Area Assessment process is to identify what needs to be care-planned, and why or why not. The documentation should include the problem, contributing and risk factors, and state if improvement is possible or decline can be minimized. CAA Summary notes should be brief but cover the essential points. Documentation for each triggered CAA should generally describe:

Nature of the issue or condition (may include presence or lack of objective data and subjective complaints).

Complications and risk factors that affect the staff’s decision to proceed to care planning.

Factors that must be considered in developing individualized care plan interventions. Include appropriate documentation to justify the decision to care plan or not to care plan for the individual resident.

Need for referrals or further evaluation by appropriate health professionals.

Written documentation of the CAA findings and decision-making process may appear anywhere in the resident’s record. The documentation can be located anywhere in the resident’s chart, and any form of CAT Summary Note is acceptable.

It can be written in discipline specific flow sheets, progress notes, in the care plan summary notes, in a CAA summary narrative, on a CAA questionnaire, etc. No matter where the information is recorded, use the “Location and Date of CAA Assessment Documentation” column on the CAA Summary form to note where the CAA review and decision-making documentation can be found in the resident’s record. Also indicate in the column “Care Plan Decision” if the triggered problem is addressed in the care plan. 

Care Area Assessment Book with Triggers and Modules 

CAA Nutritional Status 

CAA Cognitive Loss – Dementia 

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