The Resident’s Right to Participate in Care Planning

F553 in Appendix PP includes the resident’s right to participate in the development of their care plan. The regulatory language includes that the resident has the right to participate in developing and implementing their person-centered care plan which includes:

• The right to participate in the care planning process including identifying individuals or roles that are included in the process, the right to request meetings, and revisions to the person-centered care plan.
• The right to participate in establishing goals and outcomes of care including the type, amount, frequency, duration, and any other factors related to the effectiveness of the care plan.
• Notifying the resident in advance of changes to the care plan.
• The right to receive services included in the care plan.
• The right to view the care plan and sign after significant changes to the document.

The resident also has the right to be informed of their rights to participate in treatment and the planning process must facilitate the inclusion of the resident and/or their representative, include an assessment of the resident’s strengths and needs, and incorporate the resident’s preferences in developing goals.

The interpretative guidance outlines the expectations of residents (or their representatives) to be included in the care planning process. This includes ensuring that the resident or their representative understand the process, are invited to care planning meetings that are scheduled to accommodate the resident (or representatives) attending the meeting. In addition, the resident has the right to refuse items to be included in the care plan in accordance with additional resident’s right requirements. While some residents may not be able to actively participate due to cognitive impairments, their preferences and desires should be implemented to the extent practicable. For example, if the resident appears to have a negative reaction to waking up early in the morning but cannot express their preferred waking time, the nursing home should make efforts to allow the resident to sleep longer based on the appeared preference of the resident.

While it is important to document efforts made to incorporate the resident and their representative in the care planning process, it is equally as important to ensure that residents and their representatives are educated in the reason the care plan is important and what efforts you’re making to involve them. Many times when care plan deficiencies are cited, the surveyor includes evidence of noncompliance from interviews. These interviews may be with either the resident or the representative and include statements such as the resident was not familiar with what a care plan was and denied ever being invited to a meeting. When the residents or their representatives state this during an interview the surveyors will also review records to determine if there is evidence of documentation that the resident or their representative were offered to participate. If the documentation is not present it backs up the resident or the representative’s statements as there is nothing indicating the nursing home was compliant with the requirement.

Now is a great time to review your compliance with this requirement. You can select a sample of residents and review their documentation for:

• Evidence that the resident and/or their representative participated in care conferences such as sign in sheets, signatures on care plans, etc.
• If the resident or representative did not attend the conference what documented efforts to include them in the development of the care plan occurred?
• Interview residents and/or their representatives to determine if they’re aware of what the care plan is and if they’ve been invited to participate in the development of the care plan.