Staff Interviews (Interdisciplinary team (IDT) members) Across Various Shifts: How do you ensure care is provided that is consistent with the care How do you monitor care plan implementation and changes in plan? condition? Can you tell me about the resident’s care plan and his/her condition How are changes in the care plan and the resident’s condition (including underlying causes)? communicated to staff? What are the facility’s dementia care guidelines and protocols? Ask about any other related concerns the surveyor has identified. What types of dementia management training have you completed? How, what, when, and to whom do you report changes in condition? Record Review: Are the resident’s dementia care needs adequately assessed? Are pharmaceutical interventions used only if clinically indicated, at the lowest dose, shortest duration, and closely monitored? Is the care plan comprehensive? Does it address the resident’s specific conditions, risks, needs, preferences, interventions, and Was dementia management training provided to staff? include measurable objectives and timetables? Has the care plan been revised to reflect any changes? Critical Element Decisions: A. Did the facility comprehensively assess the physical, mental, and psychosocial of the resident with dementia to identify the risks and/or to determine underlying causes: Did staff identify and assess behavioral expressions or indications of distress with specific detail of the situation to identify the cause; If the expressions or actions represent a sudden change or worsening from baseline, did staff immediately contact the attending physician/practitioner; If medical causes are ruled out, did staff attempt to establish other root causes of the distress; and/or Did facility staff evaluate: The resident’s usual and current cognitive patterns, mood, and behavior, and whether these present risk to resident or others; • and/or How the resident typically communicates an unmet need such as pain, discomfort, hunger, thirst, or frustration? • B. Did the facility develop a care plan with measurable goals and interventions to address the care and treatment for a resident with dementia: Was the resident and/or family/representative involved in care plan development; Does the care plan reflect an individualized, person-centered approach with measureable goals, timetables, and specific interventions; Does the care plan include:
Staff Interviews (Interdisciplinary team (IDT) members) Across Various Shifts: How do you ensure care is provided that is consistent with the care plan? Can you tell me about the resident’s care plan and his/her condition (including underlying causes)? What are the facility’s dementia care guidelines and protocols? What types of dementia management training have you completed? How, what, when, and to whom do you report changes in condition? How do you monitor care plan implementation and changes in condition? How are changes in the care plan and the resident’s condition communicated to staff? Ask about any other related concerns the surveyor has identified. Record Review: Are the resident’s dementia care needs adequately assessed? Is the care plan comprehensive? Does it address the resident’s specific conditions, risks, needs, preferences, interventions, and include measurable objectives and timetables? Has the care plan been revised to reflect any changes? Are pharmaceutical interventions used only if clinically indicated, at the lowest dose, shortest duration, and closely monitored? Was dementia management training provided to staff? Critical Element Decisions: A. Did the facility comprehensively assess the physical, mental, and psychosocial of the resident with dementia to identify the risks and/or to determine underlying causes: Did staff identify and assess behavioral expressions or indications of distress with specific detail of the situation to identify the cause; If the expressions or actions represent a sudden change or worsening from baseline, did staff immediately contact the attending physician/practitioner; If medical causes are ruled out, did staff attempt to establish other root causes of the distress; and/or Did facility staff evaluate: • The resident’s usual and current cognitive patterns, mood, and behavior, and whether these present risk to resident or others; and/or • How the resident typically communicates an unmet need such as pain, discomfort, hunger, thirst, or frustration? B. Did the facility develop a care plan with measurable goals and interventions to address the care and treatment for a resident with dementia: Was the resident and/or family/representative involved in care plan development; Does the care plan reflect an individualized, person-centered approach with measureable goals, timetables, and specific interventions; Does the care plan include:
CMS-20133_Dementia_Care.docx