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As mentioned in the other posts talking of this issue, CMS has guidance in the SOM for nursing home surveyors to follow. The third piece of the investigation is the review of the resident’s record and other facility documents. The nursing home surveyor will review the resident’s assessment, the history and physical and other portions of the clinical record. These items should include the information needed to determine the resident’s needs and the interventions needed to meet the resident’s needs. The surveyor should be looking for consistency among the various parts of the record as well as with the observations that have been made and the interviews that were conducted.

The plan of care should be reviewed to see if it contains the detail needed to meet the resident’s needs. Each care plan should be individualized to each resident, so the surveyor is going to be looking to see that the care plan is not the same for most residents in the facility. An example of this would be “Toilet the resident before and after meals and at bedtime”. When I see this as a surveyor it starts ringing bells. Again, as mentioned before in this series of posts, everyone has their own pattern of needing to use the bathroom. Residents don’t fit into a cookie cutter. The plan should be based upon the goals, needs, and strengths specific to the resident and it should reflect the comprehensive assessment. It should identify objectives, timeframes, potential complications, and even environmental obstacles that affect the resident. Every care plan, whether for this issue or another, should identify specific approaches and interventions and should include input by the resident and/or the responsible person.

The information I have provided in the posts on this topic are just the “tip of the iceburg”. You will find much more information in the SOM and I encourage you to take some time to read and review it, especially if you are in a nursing home or have a loved one in a nursing home.

Be safe and informed!

JL

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