§483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable.
§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).
§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.
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Observations:
Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of 18 residents reviewed (Residents R172 and R173).
Findings include:
Review of a facility policy entitled, "24/48 Hour Care Conference" dated 11/07/23, indicated that a care conference was to be completed within 24-48 business hours to discuss short- and long-term goals, dietary concerns, physical limitations, interests and hobbies, medical diagnoses, physical therapy goals/concerns, billing, and care plan preferences.
Review of Resident R172's clinical record revealed an admission date of 11/28/23, with diagnoses that included Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), osteomyelitis (infection of the bone), amputation of right toes, inflammatory spondylopathy of the neck (inflammatory arthritis affecting the spine), and unstable angina (chest discomfort or pain caused by an insufficient flow of blood and oxygen to the heart).
Review of Resident R172's clinical record revealed two developed care plans: Advanced Directives dated 12/05/23, (seven days after admission), and Nutrition dated 12/06/23, (eight days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative.
Review of Resident R173's clinical record revealed an admission date of 11/30/23, with diagnoses that included respiratory failure, heart disease, heart failure, irregular heartbeat, high blood pressure, and Type 2 Diabetes.
Review of Resident R173's clinical record revealed two developed care plans; Advanced Directives dated 12/05/23, (five days after admission), and Nutrition dated 12/06/23, (six days after admission), and no evidence that a baseline care plan had been developed or a 24-48-hour care conference had been provided to the resident and/or representative.
During an interview on 12/06/23, at 11:40 a.m. the Director of Nursing and the Executive Director confirmed the 24-48-hour care conference was intended to present the resident and/or representative with the baseline care plan, there was no evidence that the baseline care plan was developed, and that the 24-48-hour baseline care plan summary had not been or provided to Residents R172 and R173 and their representatives.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.12 (d)(3)(5) Nursing Services
| | Plan of Correction - To be completed: 02/02/2024
Resident R172 and R173 had a review of their baseline care plans by the Director of Nursing. Director of Nursing developed the baseline care plans for the above mentioned residents and provided resident/responsible party a copy of the baseline care plan. Moving forward, baseline care plans will be created for all new residents within 48 hours of admission by the charge nurse.
Director of Nursing/designee will educate nursing staff on the process of developing baseline care plans. Baseline care plans for new admissions within the past 3 months, who still reside within our facility, have been audited for completion. All charts reviewed contained baseline care plans.
Baseline care plans for all new residents, moving forward, will be audited in daily clinical meetings 5 days a week times 2 weeks, weekly times 2 weeks and monthly times two months to ensure completion.
Nursing Home Administrator to monitor Director of Nursing/designee for completion of audit and to ensure baseline care plans are being developed for all new admissions. Results of audit will be reviewed at quality assurance meeting.
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