SNFs can protect themselves from this additional regulatory scrutiny through care plan training and auditing. Remember, care plans must be individualized and consistently updated. Include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs identified in the MDS assessment. Conduct a review of care plans to ensure the MDS data links to the care plan, stated goals include a measurable objective, timetables are reasonable, and documentation in the chart is consistent with the plan. Once you develop a baseline understanding of your current state of compliance with care planning requirements, perform staff training consistent with the gaps in your care planning process. Follow up with a regular care plan audit.

Discharge planning is also a key focus area for investigators. Your audit should include a specific review of discharge plans relative to the requirements. Discharge plans should include a thorough recap of the resident's stay, a description of the resident's functional status at the time of discharge, and a description of the care and services required following discharge. Resident needs and plans change frequently, so re-visit the subject of discharge periodically even if there is no short-term plan. Be certain that care plan meetings include a discussion about each resident's discharge potential and the likelihood that the resident will elect to leave. Keeping an open dialogue will give your facility the time it needs to plan discharges appropriately and safely.