Hospice agencies are faced with many regulatory challenges on a daily basis, including creating, maintaining and updating patient care plans. Care plan education is not the most exercised topic, although it is one of the most important tasks a nurse or clinician must complete. A care plan guides the entire interdisciplinary team, tracking outcomes and reflecting the changing needs of the patient and their family – making it critical to develop a quality care plan that meets compliance.

Compliance challenges in hospice care plan creation

The registered nurse (RN) case manager is designated by the Centers for Medicare & Medicaid Services (CMS) as the care plan coordinator. In this role, the RN must ensure the plan of care remains updated, individualized, relevant and realistic. This includes direction and oversight of all other disciplines in the care team, such as spiritual counselors and social workers. Often these clinicians see patients only once a month, and it can be challenging to make their care plans specific and attainable.

A number of electronic documentation software programs are equipped with prompts that generate care plan language. However, this is not a fail-safe measure to mitigate risk of deficiencies, nor should it be relied upon due to its generic language. In fact, many deficiencies studied by McBee have been a result of repetitive care plan language. A handful of state surveys reported the following deficiencies in hospice:

  • Continuation of previous care plans without updates
  • Using only software-generated care plans
  • Goals that are not measurable
  • Documentation not meeting regulatory requirements, such as falls
  • Excessive care plans left open for resolved problems
  • IDG meeting challenges without proper input by team
  • Care planning for wounds incomplete or not updated regularly
  • Plan of care not being updated at interdisciplinary group (IDG)
  • IDG team not meeting regularly or missing a member
  • Plan of care not being individualized
  • RN missed direct supervision visits with hospice aide
  • Care planning for aides incomplete or did not accurately reflect needs of the patient and family

While not all of these may be specific problems in your agency, these are just a few of the hundreds of survey items that surround care plans. Many trends seen in survey results provide evidence of barriers in effective care planning. Software language modification, time constraints, knowledge of the regulations and IDG time constraints may all contribute to challenges your agency may face. Ensuring that every discipline is reviewing and updating care plans at IDG and obtaining specialized help to assist with field staff education will ensure your care plans are complete and compliant.

Developing quality hospice care plans

In a recent document posted by the Office of Inspector General (OIG), care plans commonly cause deficiencies among hospice agencies under state survey as well as accrediting agencies. Due to this, CMS has developed a fact sheet titled Creating Effective Hospice Plan of Care that can assist in guiding agencies via a framework of requirements to identify their specific needs for care plan education.

Ensuring a care plan is individualized to a patient is key in delivering quality care. One helpful method is to utilize the SMART acronym when developing a care plan.

  • Specific: To assign care plans that focus on problems specific to the beneficiary.
  • Measurable: Must be able to assign a measurement such as a 2 cm. reduction in wound size.
  • Attainable: What can you achieve; how would you know it is being achieved?
  • Relevant: Is the care plan related to actual challenges for this person and family?
  • Time Based: Open-ended or end-of-benefit-period goal setting is not accepted.

Another path to achieving quality care plan creation is to designate a clinical team member or outside consultant to monitor, audit and regularly provide guidance. This should be an integral part of your agency’s quality program. Not all staffing models are generous enough to meet all of these needs, however and may benefit from external consultancy assistance. An external reviewer can remotely assess, identify risk areas and assist and advise in creation of an education program. This will enable staff to track, trend and plan their care optimally; and ultimately achieve positive outcomes for all beneficiaries.

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