RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
A FACILITY ASSESSMENT IS A STARTING POINT FOR A QUALITY IMPROVEMENT PROJECT. THE CHECKLIST INCLUDED IN THIS BOOKLET WILL BE USEFUL IF YOU TAKE A CRITICAL LOOK AT YOUR CURRENT PRACTICES.
IF YOU ANSWER “YES” TO ALL OF THE QUESTIONS, THE PROCESS IS ALWAYS COMPLETE AND DONE SO CONSISTENTLY. IF YOU ARE NOT SURE, OR ANSWER “NO” TO ONE OF THE QUESTIONS, CHOOSE ONE OR MORE ELEMENTS ON WHICH TO FOCUS YOUR QUALITY IMPROVEMENT. IF YOU ANSWER “NEEDS IMPROVEMENT” TO ONE OR MORE QUESTIONS, THE PROCESS IS NOT ALWAYS COMPLETE AND/OR NOT ALWAYS DONE CONSISTENTLY.
Self-Determination Screening DOES YOUR FACILTY HAVE A PROCESS FOR SCREENING THAT ADDRESSES ALL THE YES NO NEEDS BELOW LISTED AREAS? IMPROVED Does your facility have a policy and procedure for when and how the staff will screen residents who are trying to refuse, resist or direct their care in a manner which conflicts with facility/industry □ □ □ standards? Does your policy and procedure state that residents should be allowed to exercise their right to refuse treatment? □ □ □ Are residents offered acceptance or decline of changes in treatment? □ □ □ Staff promptly report resident resistance, refusal, etc. to appropriate personnel? □ □ □ Does staff promptly notify the physician of refusal, resistance, etc? □ □ □ Staff often misleads residents to doing things they know they don’t like? □ □ □ Staff may disguise medications, thickeners or other treatment s to secure compliance? □ □ □ Does staff offer alternatives that might be acceptable to the resident when he/she refuses or resists? □ □ □ Do staff question the resident as to why they may be refusing or resisting ? □ □ □
Does staff ask the resident how they have done something at home and try to incorporate that into the plan of care in the facility for the resident? □ □ □
Residents report that they are able to self-direct their care in a manner that makes them feel comfortable and in control? □ □ □
Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
A COMPREHENSIVE ASSESSMENT NEEDS COMPLETED ANY TIME A RESIDENT REFUSES TREATMENT OR DESIRES TREATMENT THAT IS OUTSIDE THE SCOPE OF PRACTICE OF THE FACILITY/INDUSTRY STANDARDS
Self-Determination: DOES YOUR FACILTY HAVE A PROCESS FOR COMPREHENSIVE ASSESSMENT YES NO NEEDS ADDRESS ALL OF THE BELOW ELEMENTS? IMPROVED Cognitive ability to make choices? (use Section G of MDS 3.0) □ □ □ Cognitive ability to understand risks/benefits of refusal/treatment? □ □ □ Legal representative status? □ □ □ Does the refusal/self-determination present a risk in any area or increase risk in any area? □ □ □ When the refusal increases risk(s) are all areas at risk assessed appropriately? □ □ □ Is assessment re-triggered anytime the risk increases or a problem develops? □ □ □ Assessments in risk areas are on-going and follow any changes that could increase risk? □ □ □
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THE CARE PLAN IS COMPLETED FOLLOWING COMPRHENSIVE AND MDS ASSESSSMENT TO DETERMINE NEEDS AND GUIDE THE INTERVENTIONS OUTLINED IN THE CARE PLAN.
Resident Self-Determination: Developing the Care Plan
DOES THE PLAN OF CARE FOR SELF-DETERMINATION ADDRESS ALL THE AREAS BELOW? YES NO NEEDS IMPROV. Does the care plan indicate that the residents’ refusal, resistance presents a problem in any area of care? □ □ □ Does the care plan for include a goal as defined by the resident/caregiver/family member? □ □ □ Does the care plan include education of the resident and family related to the Goal s and overall treatment plan? □ □ □ Are all assessed needs care planned appropriately? □ □ □
Does the plan include a wide variety of interventions which address physical, social and psychological issues? □ □ □
Does the plan demonstrate considering resident choice, preferences, and any intolerance? □ □ □ Does the plan demonstrate encouragement regarding choices? □ □ □ Does the plan address underlying causes for refusal/resistance? □ □ □
Does the plan address medication or underlying diagnoses that could contribute? □ □ □
Does the plan address medication or underlying diagnoses that could contribute? □ □ □
Does the plan educate resident to risk of not following therapeutic diet , if the resident is exercising his or her right to self-determination? □ □ □
If, the resident is exercising right to self-determination does the plan indicate that alternatives were offered, and that continued monitoring will continue with f/u to any □ □ □ continued decline? Does the plan address continued monitoring (weekly weights, f/u lab, meal audits)? □ □ □
Does the plan require review/modification if risk increases or problems develop due to self-determination, refusal or resistance? □ □ □ □ □ □
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Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
FOR RESIDENTS WHO ARE BEING TREATED FOR HIGH RISK AREAS WHICH ARE INCREASED DUE TO SELF-DETERMINATION IS A PLAN IN PLACE TO MONITOR CONTINUALLY7?
Self-Determination: Monitoring DOES YOUR FACILITY’S PROCESS FOR MONITORING INCLUDE THE FOLLOWING? YES NO NEEDS IMPROV. Observing treatment areas that the resident refuses and is at risk for each time the resident exercises his/her right to refuse, resist or self-determine? □ □ □ Does staff immediately report problems/issues related to refusal that may increase risk or be a significant care issue? □ □ □ Does documentation indicate appropriate and timely monitoring? □ □ □ Do random verbal audits of the staff indicate knowledge of who is at risk for self-determination, refusal or resistance and do they know they’re role in the management of those conditions for the □ □ □ individual? Is there indication that the staff are inquiring into the residents tolerance of variations in treatment? □ □ □ During observation is staff seen to offer choices to the resident and encourage choice? □ □ □ Does increasing risk or problem development trigger re-assessment ? □ □ □ Does increasing risk or problem development trigger review/modification of care plan? □ □ □ Do staff understand what they are monitoring and why? □ □ □
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Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
DOES YOUR FACIITY HAVE A PROCESS FOR RESCREENING/REASSESSING A RESIDENTS’ SELF-DETERMINATION IF THE RESIDENT’S CARE PLAN IS EFFECTIVE OR IF IT NEEDS REVISION?
Rescreening/Reassessing YES NO NEEDS IMPROV. Does the facility rescreen all residents on a quarterly basis or with significant change in condition? □ □ □ When those rescreens indicate risk does the facility move forward with comprehensive assessment? □ □ □ Does your staff complete rescreening correctly and timely? □ □ □ Does your staff reassess functional ability during assessment or screening of cognitively impaired residents? □ □ □ If/When cognitive ability to address refusal, resistance or self-determination decline does staff reassess and modify the care plan appropriately? □ □ □ □ □ □ □ □ □ □ □ □ □ □ □
Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
DOES YOUR FACILITY’S POLICY FOR SELF-DETERMINATION & MANAGEMENT INCLUDE THE FOLLOWING COMPONENTS?
Self-Determination: Assessing Management policies YES NO NEEDS IMPROV. Does your facility’s policy include a statement regarding the facility’s commitment to resident choice and self-determination? □ □ □ Does the policy & procedure include screening, assessment and rescreening and reassessment for on-going risk areas that are impacted by self-determination? □ □ □ Does your facility’s policy include the goals of self-determination management program such as: □ □ □
Process for assisting residents to maintain self-determination when they refuse treatments □ □ □ Assessment of why the resident is refusing or resisting? □ □ □ Identification of alternatives offered which might be more agreeable? □ □ □
On-going education of resident/responsible party as to the risks/benefits of treatment or refusal of treatment. □ □ □ Assess resident history, preference and routines that impact self-determination? □ □ □
Steps taken to monitor treatment effectiveness □ □ □
Does your policy & procedure address who, how and when self-determination management program effectiveness should be monitored and evaluated? □ □ □
Does your facility’s policy & procedure address a protocol for ongoing monitoring of self- determination status? □ □ □
Does your facility’s policy & procedure address a protocol for communication of reporting self- determination, refusal or resistance? □ □ □ Does your facility’s policy & procedure address assurance of communication across staff levels? □ □ □ Does your facility’s policy & procedure demonstrate that there is to be staff promotion of resident choice and the offering of choices? □ □ □
Does your facility’s policy & procedure indicate appropriate notification of responsible party/family and physician for self-determination that conflicts with PO, Policy, Standards, etc. □ □ □ Does your facility’s policy & procedure address ongoing education, orientation of new employees and education of self-determination policy and facility commitment to residents and family? □ □ □
Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
DOES YOUR FACILITY’S EDUCATION PROGRAM FOR SELF-DETERMINATION & MANAGEMENT INCLUDE THE FOLLOWING COMPONENTS?
Self-Determination: Assessing Staff Education and Training YES NO NEEDS IMPROV. Is new nursing staff provided training and education on self-determination, resident right to refuse, screening, assessment, reassessment and management? □ □ □ Is current staff provided ongoing education on the principles of resident rights and self- determination? □ □ □ Does staff responsible for ongoing education provide discipline specific education on assessment, and management of self-determination? □ □ □ Is there a designated clinical “expert” available at the facility to answer questions from all staff about self-determination and management? □ □ □ Does staff education take into consideration the personal, ethnic, cultural and religious beliefs surrounding resident choice? □ □ □ Does education include proper staff training on documentation methods related to cognitive ability, psychosocial well-being when choices are limited or taken away? □ □ □ Does education include meeting the resident’s self-direction when that self-direction conflicts with facility policy or recognized clinical standards surrounding any treatment? □ □ □ □ □ □
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Completed by:______Date:______RESIDENT SELF-DETERMINATION FACILITY ASSESSMENT CHECKLISTS
THIS QUESTIONNAIRE SHOULD BE COMPLETED BY DIRECT CARE STAFF OR THE INTERDISCIPLINARY TEAM. CONSULT WITH APPROPRIATE STAFF IN ANSWERING CERTAIN QUESTIONS AND COMPLETING THE ABOVE CHECKLISTS. IF YOU ANSWER “NO” TO ANY QUESTON BELOW, PLEASE REVIEW THE CHECKLIST REFERENCED BY THE PAGE AFTER THE QUESTION. IF YOU ANSWER “YES” TO A QUESTION, THE PROCESS IS ALWAYS COMPLETE AND DONE SO CONSISTENTLY. IF YOU ANSWER “IN PROGRESS” TO ANY OF THE BELOW QUESTIONS, THE NEED IS BEING ADDRESSED BUT NEEDS IMPROVEMENT AND REASSESSING AT A LATER DATE.
Self-Determination: Overview & Summary of Facility Assessment YES NO IN PROGRESS Does your facility have a process for when and how the staff will screen residents for self- direction? ( Page 1) □ □ □ Does your facility complete a comprehensive assessment for in all areas where self-determination increases or poses risk? (Page 2) □ □ □ Does your facility have a process for developing and implementing a care plan for Self- Determination (Page 3) □ □ □ For residents who are exercising self-determination does the facility have policy for ongoing screening of such residents. □ □ □ (Page 4) Does your facility have a process for reassessing a resident’s self-determination status for determining the care plan’s effectiveness or need of revision? (Page 5) □ □ □ Does your facility have a policy for self-determination & management? (Page 6) □ □ □ Does your facility have an initial and ongoing education on self-determination & management for both nursing and non-nursing staff and for new staff? (Page 7 □ □ □ Review the facility Quality Assurance Program are measurable parameters included regarding self- determination assessment and management? □ □ □
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