Documentation

Long-Term Care Documentation in Kansas

Accurate and thorough documentation is essential for ensuring continuity of care, legal compliance, and resident-centered service in Kansas long-term care (LTC) facilities. Both Social Service Designees (SSDs) and Activities Directors (ADs) play key roles in maintaining documentation that reflects individualized needs, psychosocial progress, and meaningful engagement in care planning and activities.

Regulatory Requirements in Kansas

Documentation in LTC facilities must comply with federal Centers for Medicare & Medicaid Services (CMS) regulations as well as Kansas Department for Aging and Disability Services (KDADS) guidelines. Facilities must maintain complete and timely records of care plans, assessments, social histories, activity participation, and psychosocial interventions.

• Federal regulation: 42 CFR § 483.10 – Resident Rights and Facility Responsibilities
• Kansas regulation: K.A.R. 26-39-101 et seq. – Adult Care Home Licensure
• Retention: Documentation should be retained for at least five years post-discharge or as specified by facility policy.

Minimum Data Set (MDS) and Documentation

The Minimum Data Set (MDS) 3.0 is a federally mandated assessment tool that provides a standardized method for collecting essential data on residents in certified nursing facilities. SSDs and ADs contribute to the completion of MDS items related to:

• Psychosocial well-being
• Preferences for activities and routines
• Participation in care planning
• Social engagement and support systems

Documentation must support the MDS entries and include resident interviews, observations, and interdisciplinary input. Errors or inconsistencies in documentation can negatively affect reimbursement and quality measures.

Form Types and Sample Descriptions

Common documentation forms used by SSDs and ADs include:

• Social History Form: Includes background information on the resident’s family, occupation, religious beliefs, cultural identity, education, and previous living arrangements.
• Progress Notes: Narrative entries reflecting psychosocial observations, interventions, responses to activities, and behavior changes. Example: “Resident expressed grief over spouse’s death, referred to counseling support.”
• Activity Participation Records: Track attendance, level of engagement, and resident preferences for activities. Some facilities use coding systems such as E=Engaged, R=Refused, A=Asleep.
• Care Plan Summary: Identifies specific goals and interventions related to social and emotional health or meaningful activities.
• Assessment Tools: Instruments such as PHQ-9 for depression screening or interest checklists help guide service planning.

Documentation Tips

• Use objective, descriptive language – avoid personal judgments.
• Write in real-time or as soon as possible after an event occurs.
• Use facility-approved abbreviations and terminology only.
• Ensure consistency between documented observations and MDS entries.
• When documenting refusals, include what was offered, how it was presented, and the resident’s response.
• Correct errors per facility policy (usually by drawing a single line through the mistake, initialing, and dating the correction).

Quality Assurance and Documentation

Documentation plays a critical role in a facility's Quality Assurance and Performance Improvement (QAPI) program. Inaccurate or incomplete records can impact:

• Resident care outcomes
• Survey results
• Medicare/Medicaid reimbursement
• Legal liability

SSDs and ADs may be asked to participate in QAPI teams, review chart audits, or monitor psychosocial and activity-related outcomes for improvement opportunities.

Care Plan Development

SSDs and ADs contribute unique perspectives to the resident care plan. Documentation should reflect individualized goals, such as:

• “Resident will participate in small-group music activities twice weekly to reduce social isolation.”
• “Resident will verbalize reduced anxiety after three counseling sessions.”

Care plans must be updated when there are significant changes in a resident’s condition, preferences, or behavior. Documentation of progress or lack thereof is critical to support changes.

Assessment Schedules

Assessment timelines are regulated by CMS. Accurate documentation supports timely reassessment and ensures compliance. Common assessment windows include:

Conclusion

Effective documentation supports the physical, emotional, and social well-being of residents in Kansas long-term care facilities. For SSDs and ADs, detailed and person-centered records ensure resident dignity, regulatory compliance, and quality care planning. Staying current with best practices in documentation helps improve interdisciplinary collaboration, enhances outcomes, and protects the integrity of services provided.