CMS recently published changes to the MDS RAI Manual. Revisions include:
Section G wording of the Activities of Daily Living definitions
Section H Toileting Program criteria
Section M pressure ulcer staging criteria
Section O Influenza Vaccine coding and wording of Planning for Care
Section O Therapy coding
RAI Manual v1.12 Change Tables_October 2014
Nursing care plans are blueprints for residents’ entire care needs, and direct the actions of all health care team members. Written 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:
CMS published Advance Guidance for the Revisions to the State Operations Manual (SOM), Appendix PP- Guidance to Surveyors for Long-Term Care (LTC) Facilities and Chapter 4 on July 3, 2014.
Revisions made to Appendix PP include:
Labeling of Drugs and Biologicals/Storage of Drugs and Biologicals – F281
Electronic Signature Guidance – F278
Exceptions to the Observation Requirement When Determining Significant Medication Errors – F332
Physician Delegation of Tasks – F387
Use of Insulin Pens, Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections, Point of Care Devices, Laundry and Infection Control – F441
Surveying Facilities that use Electronic Health Records – F514
Highlights of state Operations Manual Revisions July 2014
New dementia care surveyor guidelines were released by CMS March 24, 2014.
The guidelines focus on basic quality measures and dementia care principles: Person-centered care, quality and quantity of staff, thorough evaluation of new or worsening behaviors, individualized approaches to care, critical thinking related to antipsychotic drug use, interviews with prescribers, and engagement of the resident or representative in decision-making
Dementia Care in Nursing Homes F309 and F329