Frequently Cited Deficiencies and Common Compliance Strategies - Plan of Care Contents for Class A Agencies

This is for informational purposes only. Following this guidance does not guarantee you will pass the survey visit. What follows are examples of some, but not all causes of deficient practice. This guidance is not intended to be the best or the only way to be compliant.
6 CCR 1011, Chapter XXVI, section 7.10(A)(1) - Plan of Care Contents (L365)
“The plan of care shall be developed in consultation with the agency staff and covers all pertinent diagnoses, including mental status, types of services, identification of any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, instructions for timely discharge or referral and any other appropriate items.
(a) The plan of care shall identify the consumer's continuing need for home care and meet the consumer's medical, nursing, rehabilitative, social and discharge planning needs.

(b) The plan of care reflects the participation of the consumer to the extent possible. The HCA communicates the plan of care to the consumer/caregiver in a comprehensible way.”
Common Causes of Deficient Practice
  • Scenario 1: Care plans do not assign a frequency of visits for each ordered discipline
Care is often ordered at a specific frequency. For example, a physician may order wound care three times a week to ensure continual monitoring and treatment of a wound. It is critical to the health of the consumer that care is provided in the frequency ordered. When care is neither assigned nor carried out at a frequency ordered by the physician, the consumer's health, physical status and satisfaction with services could be compromised.
Excerpt from a deficiency list
"Review of the current Plan of Care, completed by RN #2 on 07/20/16, identified the CNA services the consumer was to receive under the section titled, "Orders For Discipline and Treatments." RN #2 did not note the frequency and duration of CNA visits the agency was to provide.
During interview on 12/08/16 at 4:25 p.m., the fact that the agency's Plans of Care lacked specific information related to the frequency and duration of services was discussed. The agency owner explained that due to the nature of private paid arrangements, the consumer was free to select the amount and type of services requested.
However, irrespective of the payer source, licensure rules require agencies providing skilled services to include specific information related to frequency and duration of services on each consumer's Plan of Care."
  • Scenario 2: Care plans lack specific instruction on the provision of a task.
Some consumers require that certain tasks be provided at a certain interval and with specific equipment. Tasks like wound care and catheter care require detailed instructions about how to safely provide care with the proper equipment. It is critical to consumer safety that such instructions are assigned on a care plan and closely followed by each clinician.
Excerpt from a deficiency list
"The clinical record for Consumer #7 was reviewed on 11/15/16. The Plan of Care for the period dated 09/11/16 to 11/09/16 revealed a start of care date of 05/14/16; diagnoses included infected surgical wound and diabetes mellitus. Plan of Care orders included SN visits once daily for seven days to provide skilled assessment, wound assessment with each dressing change, consumer education on diabetic management, change central intravenous (IV) line dressing once weekly and flush central line with normal saline daily prior to IV medication administration; and physical therapy (PT) to evaluate and treat.
Review of a comprehensive assessment for the period dated 09/11/16 to 11/09/16, completed on 09/07/16 by RN #18, revealed Consumer #7 had a surgical wound on his/her right ankle that required wound vacuum assisted closure (VAC) therapy.  

Review of an order dated 09/12/16, for the period dated 09/11/16 to 11/09/16, showed an order for wound VAC therapy at 125mm/Hg continuous pressure to be changed three times weekly.

However, there was no documentation of wound care orders listed on the Plan of Care instructing the SN on the frequency and type of wound care to be performed.

During an interview conducted on 11/17/16, at 1:07 p.m., RN #18 was presented with Consumer #7's Plan of Care for the certification period dated 09/11/16 to 11/09/16. Upon review, RN #18 agreed there were no wound care orders listed on the Plan of Care and stated s/he had no idea why the Plan of Care did not contain the order. RN #18 further stated s/he did not know how the Plan of Care was generated and had not reviewed it prior to it being sent to the physician for signature."
Common Compliance Strategies
Successful agencies provide extensive initial and ongoing clinician training on the importance of developing and following a specific plan of care. The training is catered to the role each staff person plays in obtaining orders, developing care plans, and carrying out the care.
Agencies train staff who receive referral orders to review them for the level of specificity required by rule and provide instruction on how to follow up with medical professionals when clarification is needed. For instance, if an order for wound care does not contain sufficient details about the types of supplies to use or does not clearly identify the location of each wound, they are instructed to contact the ordering physician to obtain clarified orders. The agencies also ensure field clinicians are trained to recognize an inadequate plan of care and go through the proper channels to obtain clarifications. The clinicians are instructed to never make assumptions about the intention of a confusing plan of care and proceed with providing services based on their assumptions. Quality assurance staff are trained to closely review plans of care and are given the support of leadership to point out incomplete plans of care and require correction.
Successful agencies keep the issue of care plan accuracy and completeness in mind as they carry out quality management program activities. Since there is a real risk to consumer health and safety, care plan accuracy is often made a focus of routine quality management activities, such as chart audits, employee performance evaluations, and data gathering efforts. Chart audit tools contain prompts to scrutinize each care plan for completeness and clarity. Employee performance evaluations include an assessment of the employee's compliance with care planning requirements. Quality management-driven data gathering includes the collection of information such as: which medical professionals issue non-specific orders; instances of clinicians providing care based on incomplete care plans; instances in which quality assurance measures failed to identify problems with care plans, etc. Attention to such risk indicators are constantly monitored. When non-compliant patterns and trends are identified, operational changes are made and staff training and counseling is completed. To correct an identified problem, the agency takes proactive steps to ensure appropriate care planning, rather than continually correcting errors after they occur.