CMS SOM App. PP, Tag F553

person-centered plan of care, including but not limited to:

(i) The right to participate in the planning process, including the right to identify

individuals or roles to be included in the planning process, the right to request

meetings and the right to request revisions to the person-centered plan of care.

(ii) The right to participate in establishing the expected goals and outcomes of care, the

type, amount, frequency, and duration of care, and any other factors related to the

effectiveness of the plan of care.

(iii) The right to be informed, in advance, of changes to the plan of care.

(iv) The right to receive the services and/or items included in the plan of care.

(v) The right to see the care plan, including the right to sign after significant changes to

the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her

treatment and shall support the resident in this right. The planning process must—

(i) Facilitate the inclusion of the resident and/or resident representative.

(ii) Include an assessment of the resident’s strengths and needs.

(iii) Incorporate the resident’s personal and cultural preferences in developing goals of

care.

INTENT §483.10(c)(2)-(3)

To ensure facility staff facilitates the inclusion of the resident or resident representative in all

aspects of person-centered care planning and that this planning includes the provision of services

to enable the resident to live with dignity and supports the resident’s goals, choices, and

preferences including, but not limited to, goals related to the their daily routines and goals to

potentially return to a community setting.

GUIDANCE §483.10(c)(2)-(3)

Residents and their representative(s) must be afforded the opportunity to participate in their care

planning process and to be included in decisions and changes in care, treatment, and/or

interventions. This applies both to initial decisions about care and treatment, as well as the

refusal of care or treatment. Facility staff must support and encourage participation in the care

planning process. This may include ensuring that residents, families, or representatives

understand the comprehensive care planning process, holding care planning meetings at the time

of day when a resident is functioning best, providing sufficient notice in advance of the meeting,

scheduling these meetings to accommodate a resident’s representative (such as conducting the

meeting in-person, via a conference call, or video conferencing), and planning enough time for

information exchange and decision making.

A resident has the right to select or refuse specific treatments options before the care plan is

instituted, based on the information provided as required under §483.10(c)(1), (4)-(5), F552.

While Federal regulations affirm a resident’s right to participate in care planning and to refuse

treatment, the regulations do not require the facility to provide specific medical interventions or

treatments requested by the resident, family, and/or resident representative that the resident’s

physician deems inappropriate for the resident’s medical condition.

A resident whose ability to make decisions about care and treatment is impaired, or a resident

who has been declared incompetent by a court, must, to the extent practicable, be kept informed

and be consulted on personal preferences.

The resident has the right to see the care plan and sign after significant changes are made.

PROCEDURES §483.10(c)(2)-(3)

During observations, interviews, and record reviews, surveyors must:

• Interview the resident, and/or his or her representative to determine the level of

participation in care planning.

• Identify ways staff involve residents and/or their representative(s) in care planning.

• Determine if care plan meetings are scheduled to accommodate residents and/or their

representative.

• Determine how facility staff addressed questions or concerns raised by a resident or his or

her representative, including if they are addressed at times when it would be beneficial to

the resident, such as when they are expressing concerns or raising questions.

• Determine if the resident and representative were unable to participate, did facility staff

consult them in advance about care and treatment changes.

• Interview staff to determine how they inform residents or their representative of their

rights and incorporate their personal preferences, choices, and goals into their care plan.

• When the resident request is something that facility staff feels would place the individual

at risk (i.e., the resident chooses not to use the walker, recommended by therapy), is there

a process in place to examine the risk/benefit and guide decision-making?

• Review the resident’s medical record to determine if facility staff included an assessment

of the resident’s strengths and needs and whether these, as well as the resident’s personal

and cultural preferences, were incorporated when developing his or her care plan.

• Determine how facility staff observes and responds to the non-verbal communication of a

resident who is unable to verbalize preferences (i.e., if the resident spits out food, is this

considered to be a choice and alternative meal options offered).

POTENTIAL TAGS FOR ADDITIONAL CONSIDERATION

If facility staff do not provide access to the care plan within 24 hours (excluding weekends and

holidays) or provide, if requested, a copy of the care plan in written or electronic form within

two working days of the request, see §483.10(g)(2)-(3), F573, Right to Access/Purchase Copies

of Records.

If facility staff do not provide a summary of the baseline care plan to the resident and their

representative, see §483.21(a), F655, Baseline Care Plans.

Also refer to §483.21(b), F656, Comprehensive Care Plans for more information on Care Plans.