CMS SOM App. H, Tag V559

(3) If the expected

outcome is not achieved, the interdisciplinary team must adjust the patient’s plan of care to

achieve the specified goals. When a patient is unable to achieve the desired outcomes, the

team must—

(i) Adjust the plan of care to reflect the patient’s current condition;

(ii) Document in the record the reasons why the patient was unable to achieve the goals;

and

(iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii)

of this section.

Interpretive Guidance § 494.90(b)(3)(i), (ii) and (iii)

If the current plan of care has not been successful in achieving the goals identified by and for the

patient within the identified timetables, there must be evidence that barriers to achievement of

the goals were identified and that the plan was reviewed and revised, as indicated. For example,

if the patient’s Kt/V is below the expected goal for more than one month, the physician or the

non-physician practitioner might adjust the dialysis prescription by extending the treatment time

or changing the dialyzer. If the patient’s Kt/V remained below target the following month, the

team should collaboratively identify the potential reasons the patient is not reaching the

minimum goal for hemodialysis adequacy and implement changes in the plan of care to address

and resolve the identified barriers. This example would not require a reassessment and

completely new plan of care; if this is the only area where the goal was not met, the patient could

be considered “stable,” and only the plan of care for adequacy would require adjustment.

This requirement is not met if the patient’s plan of care is not adjusted to reflect the patient’s

current condition and there is no evidence that the IDT is working to address ongoing problems

(e.g., uncontrolled hypertension, hyperkalemia, missed treatments, inaccurate or unattainable

target weight) which may result in adverse outcomes for the patient. This requirement is not

satisfied if the only reason documented for failure to achieve goal(s) is “patient noncompliance”

or “non-adherence.” If the team believes the cause of the failure to reach the goal is non-

Page 223 of 420

adherence, the IDT efforts should focus on identifying potential causes of the non-adherence and

addressing those causes. The IDT must recognize each patient has the right to choose less than

optimal care when the patient determines optimal care would negatively impact their quality of

life.

These regulations require the IDT to demonstrate its members are actively attempting to meet

each patient’s plan of care goals. This Condition does not “require” a patient to meet every

goal. Any member of the IDT, including the patient, may document why goals are not met or

cannot be met.