§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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
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Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 16 sampled residents. (Resident 15)
Findings include:
Clinical record review revealed that Resident 15 was admitted to the facility on March 17, 2025, and had diagnoses that included depression. The Minimum Data Set Care Area Assessment summary dated March 23, 2025, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration record in March and April 2025, revealed the resident was receiving an antidepressant. There was no documented evidence that interventions to address Resident 15's psychotropic drug use were included in the current care plan.
In an interview on April 9, 2025, at 2:40 p.m., the Director of Nursing confirmed there was no documented evidence that the care area was addressed in the Resident 15's current care plan.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 05/10/2025
Preparation and/or execution of this place does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or maybe discussed in this response and plan or correction. This plan of correction is submitted as the Facility's credible allegation of compliance
- Resident 15 did not have any complications from observation.
- Education to staff on completion of careplans to include appropriate interventions for psychotropic medication use
- Random Audits to be completed by DON/Designee on current resident's comprehensive care plans for appropriate interventions for residents on psychotropic medications
weekly x 4, monthly x 4 Result of these audits will be reviewed at QAPI meeting for further recommendation as indicated.
- Date certain 5/10/2025
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