§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to discharge planning for one of six records reviewed (Resident R2).
Findings include:
Review of clinical documentation revealed that Resident R2 was admitted to the facility on August 26, 2023 and had diagnoses including, but not limited to, bipolar disorder, alcohol dependence, and chronic pain. Further review revealed that the resident had been issued a discharge notice, dated March 4, 2025, which stated "we are hereby notifying you that effective April 4, 2025, which is thirty (30) days from the date of this letter, you will be discharged from [the facility]". The documented reason was "the resident has failed ...to pay for ...a stay at the facility".
Review of the resident's care plan revealed that she had a care plan developed on January 14, 2025, which stated "[Resident R2] plans to remain at [the facility] for LTC (Long Term Care) placement".
Interview with the Nursing Home Administrator (NHA), employee E1, and the social worker, employee E3 on April 30, 2025, at 12:32 p.m. revealed that social services had been working with the resident to find housing placement that meets the needs and expectations of the resident since her hire in February 2025. Employee E1 confirmed that the resident's care plan had not been updated to reflect the change in discharge planning status.
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (d)(5) Nursing services
| | Plan of Correction - To be completed: 06/15/2025
Resident R2 careplan has been updated to reflect the change in discharge planning status.
An initial audit of current residents has been conducted to ensure the discharge careplan is reflective of the residents discharge planning status. New admissions will be reviewed during clinical meeting to ensure the discharge planning status is current and/or updated as indicated with changes.
The DON or designee will re-inservice the Social Workers on the Discharge Policy with the focus on careplans.
The Social Worker or designee will conduct weekly audits of 10 residents to verify discharge careplans are reflective of the residents current discharge planning status. Results of the audits will be presented at the QAPI meetings for review and/or recommendations.
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