Guest Columns

Care plans and discharge planning: Steps for success!

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Lisa Thomson
Lisa Thomson

At the end of February, the Office of Inspector General published a report called, “Skilled Nursing Facilities Often Fail To Meet Care Planning and Discharge Planning Requirements."

After reading it, there may be a few questions we ask ourselves:

  1. Are our care plans systematically developed to include individualized assessment information and in accordance with the RAI Process?
  2. Is our communication and documentation system successful in providing staff the direction on how to obtain and follow care plan interventions towards resident goals for quality? 
  3. How are we ensuring consistent implementation of the care plan interventions? 
  4. What is our process for quality interdisciplinary discharge planning (including the physician)? 
  5. Does our discharge planning process include follow up?


Let's take a look at the facility policies and procedures to determine that they include how the facility will ensure that the care plans are developed utilizing resident individualized assessment information, resident choice and updated to reflect current needs.


  • What is our protocol/procedure for discharge care planning from admission?  
  • How does our policy/procedure address assessing resident needs, cognition, physical and psychological status for discharge?  
  • Does our policy/procedure address collaboration and communication with other post-acute entities (home health, assisted living, etc.) to ensure a successful transition if the resident is unable to return home independently? 
  •  What services will be necessary?  
  • What follow up communication is included in the policies/procedures?



Next, we will want to educate the facility staff in the policies and procedures as well as a system to evaluate staff compliance with the policies and procedures. 


Other opportunities for education include:

  • Ensuring staff are providing services consistent with the identified care plan goals and interventions
  • Resident choice
  • How to analyze assessment information for development of an individualized care plan.
  • Root cause analysis approach to assessment, progress of goals, resident participation and collaboration with other entities in the successful discharge of the resident.




A common problem is documentation around care and discharge plans. You should ask:


1.     Is there evidence of comprehensive assessment in the medical record?

2.     Does the care plan coincide with resident choices and comprehensive assessment?

3.     Are the care plan goals realistic, measureable and individualized?

4.     Is there evidence that the care plan interventions are consistently implemented?

5.     Is there evidence of a discharge plan consistent with the assessed needs and functional ability of the resident for a successful transition?



Is there a system in place to communicate the care plan goals and interventions with the interdisciplinary team?



Do we have a system in place to review the care plans, communication, problem solving and education?

Do we have a system to follow up with the resident following discharge?



If there are identified areas that need to be updated in our system, we can develop an action plan to address:

  •             The specific areas that need to be updated (i.e. policies, education, documentation etc.)
  •             Your recommended plan of action
  •             Responsible discipline/position
  •             Date this will be completed


The action plan can then be discussed and worked on by the team during the next Quality Assurance Committee for review and recommendations.


Once our system is in place, we can audit on a regular basis to ensure that we are in compliance with care plans and discharge planning in the facility in order to provide quality care based on each individual's needs!


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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.