|§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.
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of two residents reviewed (Residents R1 and R2).
Review of Resident R1's clinical record revealed an admission date of 10/01/21, with diagnoses that included history of falling, high blood pressure, heart disease, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), difficulty walking, and Alzheimer's disease (a disease that destroys memory and other important mental functions).
Review of Resident R1's clinical record lacked evidence that a baseline care plan was developed and provided to the resident and/or resident's representative.
During an interview on 12/08/21, at 4:39 p.m. the Director of Nursing (DON) confirmed that a baseline care plan had not been developed and provided to the resident and/or resident's representative for Resident R1.
Review of Resident R2's clinical record revealed an admission date of 10/25/21, with diagnoses that included Dorsalgia (back pain), history of falling, chronic respiratory failure, and hyperlipidemia (high cholesterol and triglycerides in the blood).
Review of Resident R2's clinical record lacked evidence that a baseline care plan was developed and provided to the resident and/or resident's representative.
During an interview on 12/08/21, at 4:39 p.m. the DON confirmed that a baseline care plan had not been developed and provided to the resident and/or resident's representative for Resident R2.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.11(e) Resident care plan
| ||Plan of Correction - To be completed: 01/12/2022|
The two residents identified have discharged from the facility.
Residents admitting to the facility have the potential to be affected. A baseline screen was completed on all residents admitted within the last thirty days to identify if documentation is present to verify that a presentation of a baseline care plan was given to the resident or responsible party.
The NHA/DON or designee will be responsible for education of RNs, LPNs, and Social Worker regarding interim/baseline care planning policy.
The NHA/DON or designee will be responsible for ongoing compliance monitoring. The facility will conduct baseline care planning audits to check for completion three times a week for four weeks and then two times per week for four weeks.. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.