§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
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Observations:
Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to develop a comprehensive, individualized discharge care plan for three of three closed record residents discharged to the community (Residents CR1, CR2 and CR3).
Findings include:
Review of the facility policy entitled "MDS (Minimum Data Set - periodic assessment of resident care needs)/RAI (Resident Assessment Instrument - guidelines for completion of the MDS)/Care Planning" dated 11/20/21, revealed that a written, individualized plan of care would be developed for every resident which identifies through an assessment process his/her strengths and needs.
Review of Resident CR1's clinical record revealed an admission date of 9/13/20, and diagnoses that included chronic obstructive pulmonary disease (COPD - a respiratory disease characterized by obstructed airways and shortness of breath), low back pain and a history of drug abuse.
Review of Resident CR1's clinical record revealed that upon admission, Resident CR1 planned to remain in the facility for long term care. August 2021, Social Service (SS) Notes revealed efforts, per Resident CR1's request, to be transferred to another facility. October 2021, SS Notes indicated arrangements to obtain a primary care physician, pain clinic and apartment in Resident CR1's prior community. November 2021, SS Notes revealed a consult for home health, physical and occupational therapy services, which Resident CR1 declined; testing for oxygen use at home; and discharge arrangements for an apartment in Resident CR1's prior community and discharge on 11/10/21.
Resident CR1's clinical record lacked an individualized, comprehensive discharge care plan with a goal, interventions taken/planned by the facility to arrange for Resident CR1's discharge to the community and updates/changes to the discharge goal from long term placement to discharge to the community.
Review of Resident CR2 's clinical record revealed an admission date of 9/14/21, and diagnoses that included fractured right femur (bone extending from the pelvis to the knee) and pelvis, COPD, and depression.
Review of October 2021, SS Notes indicated that on admission Resident CR2's case worker requested involvement in care plan meetings and the discharge planning process and that Resident CR2's group home was in contact with the facility related to the discharge plan. An 11/23/21, SS Note indicated that Resident CR2 was discharged to a group home with a follow-up physician appointment and Nursing, Physical Therapy and Occupational Therapy consults in place.
Resident CR2's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR2's discharge to the community.
Review of Resident CR3's clinical record revealed an admission date of 11/05/21, and diagnoses that included exploration of a left hip prosthesis (artificial part), depression and diabetes.
Review of SS Notes, dated 11/15/21, indicated that Resident CR3's discharge plan was for a short term stay. SS Notes, dated 11/16/21, and 11/17/21, revealed arrangements for physical therapy, occupational therapy and nursing services following discharge, and a physician follow-up appointment scheduled on 11/22/21. SS notes reflected Resident CR3 was discharged home with family on 11/18/21.
Resident CR3's clinical record lacked an individualized, comprehensive discharge care plan with a goal and interventions to reflect the steps taken/planned by the facility to arrange for Resident CR3's discharge to the community.
During an interview on 12/02/21, at 1:15 p.m. the Director of Nursing confirmed that all residents should have an individualized plan of care related to discharge that reflects the resident's discharge goal and interventions to meet that goal.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 12/23/2021
"The Facility submits this Plan of Correction under procedures established by the Department of
Health in order to comply with the Department's directive to change conditions which the
Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of
Correction should not be construed as either a waiver of the facility's right to appeal or challenge the
accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or
Federal regulatory requirements."
F656
1. The facility cannot correct that residents CR1, CR2 and CR3 did not have a comprehensive,
individualized discharge care plan. Resident CR1, CR2 and CR3 are no longer in the facility.
2. The Social Service Director/designee will review current resident care plans to ensure there is a
comprehensive, individualized discharge care plan developed.
3. The Social Service Director will be re-educated by the Regional Social Services Consultant on the
facility policy for MDS/RAI/Care Planning with emphasis on discharge planning.
4. The MDS nurse/designee will audit five resident care plans weekly for four weeks and monthly for
three months to ensure residents have a comprehensive, individualized discharge care plan. Outcomes
will be reported to the Quality Assurance Performance Improvement Committee for review and
recommendations.
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