GUIDELINES FOR USE OF THE

IOWA PASRR CARE PLANNING TOOL

Federal law (42 CFR 483.100 -138) requires that nursing facility residents evaluated through the Preadmission Screening and Resident Review (PASRR) process receive all services identified as needed in the PASRR Summary of Findings Report. The nursing facility is responsible for reviewing the PASRR report and addressing those recommendations, by incorporating all PASRR identified services into the plan of care. This includes all rehabilitative services, specialized services, and any services that may relate to short term approval and/or preparation for discharge to a lower level of care.
The Iowa Department of Human Services has developed a care planning tool and offers it to nursing facilities for use in attempting to implement care plans that are compliant with PASRR. The examples in this care planning tool are meant to be used as guidelines and examples and should not be considered concrete or final wording that can/should be used in your care plans. There will never be one document or template that can envision all of the language that may be needed in order to write and implement person centered, individualized care plans, but we hope that nursing facilities will find this tool and the accompanying guidelines useful in care planning.
Quality principles for care-planning, specific to PASRR
  • Does the Care Plan specifically incorporate and address all of the PASRR-identified specialized services, rehabilitative services,community placement support, and other supports?
  • Is the Care Plan person-centered?
  • Has the resident, their guardian, POA for health care, family, or any desired others been included in the goal-setting and care planning process?
  • Is recovery based and person first language used throughout the document?
  • Has the Care Plan been updated to note progress or change?
  • If the resident has refused a service, does the Care Plan document the refusal and specifically reflect the facility’s plan to continue to address the identified issue(s) with the resident?
  • Does the care plan also reflect the facility’sefforts to find and implement an appropriate alternative means to address the needed service/concern(s)?

Focus –In simple terms, identify the concern or need from the resident’s perspective (“I/ (name) feel(s), I like/do not like, I have…”). Identify and describe the nature of the concern, underlying cause(s) (why is this happening?), contributing factors, risk factors and their effect on the resident.

It may not be an ideal strategy, but you may state the focus from the resident’s perspective with PASRR as a cause for the particular area of focus.

Goal –State the desired result or outcome from the resident’s perspective. Goals should be specific, individualized, measurable, and have a timeframe for completion or evaluation.

Intervention –Identify what the resident wants and needs to have occur in order to achieve the goal. Resources and services should be specific and individualized. Identify specifically how the resources or services will be implemented and by whom. For example: name the service providers/agencies, start date,as well as the anticipated frequencyand duration of the service.

Include how the resident’s strengths, skills, and abilities can be recognized, encouraged, and/or promoted.

Person/position responsible -Identify the person/people responsible for delivering the service or completing the task(s) and any particulars about how the service will be delivered and individualized to the person. In the case of any specialized behavioral health related services, please name the psychiatrist and/or individual therapist or other behavioral health provider or agency. Also, identify the role of the individual, their family and any other natural supports, in the implementation/delivery of the service.

Federal Considerations in Care Planning

CMS (42 CFR 483.20(k) (1) & (2), Appendix PP of SOM) provides some quality principles for care plans. Some key quality indicators, in addition to those on the previous page, include:

  • Does the Care Plan address and describe the services needed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being?
  • Does the Care Plan address the individual’s needs, strengths, and preferences identified in the comprehensive resident assessment?
  • Does the Care Plan reflect standards of current professional and evidence based practice?
  • Is the care plan oriented toward preventing avoidable declines in functioning or functional levels? How does the care plan attempt to manage risk factors? Does the care plan build on resident strengths?

Resources:

For technical assistance on PASRR related care planning, please contact Iowa PASRR program manager, Lila Starr, at , or 515-281-5318.

For questions or assistance, you may use resources found on the Iowa PASRR provider’s website: including the care planning tool.

The (federal) PASRR Technical Assistance Center offers substantial resources and monthly webinars:

You may also contact the Office of the (Iowa) State Long Term Care Ombudsman, 515-725-3333, or 866-236-1430 toll free.