§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.
|
Observations:
Based on review of the clinical records and interviews with staff, it was determined that the facility failed to ensure that a person-centered plan of was developed for a personal pet and a resident with suicide ideation for 2 out of 21 residents reviewed (Resident R88 and R14).
Findings include:
Review of the facility policy, "Pet Protocol," with a revision date of August 18, 2025, indicated that all animals residing in or visiting the community will have preventive care to ensure that they do not pose a risk to the health, safety, or rights of all residents. The policy also stated that the admission coordinator or a member of the life enrichment community at the facility (activity department) should be contacted to request policies/ forms should a resident want to bring a pet into the facility. Continued review of the policy indicated that a pet care plan will be completed for each pet residing in the community.
Review of Resident R88's clinical included the following diagnoses: anxiety, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), high blood pressure, seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness); hyperlipidemia (high cholesterol); agoraphobia (involves fearing and avoiding places or situations that might cause panic and feelings of being trapped, helpless or embarrassed) with panic disorder (a sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause); pain; repeat falls, and alcohol abuse.
Review of Resident R88's clinical record indicated that the resident had been receiving care at the facility since May 2025.
During an interview with Resident R88 on August 7, 2026, at 9:00 a.m. the resident was observed in his/her room with a dog. The resident reported that the dog lives at the facility and that he sleeps in his/her bed at night.
Review of Resident R88's person-centered plan of care did not include a plan of care for the resident's dog who was residing at the facility to ensure proper care, services, safety measures implemented for the dog, and other residents at the facility.
During an interview with the Director of Nursing (DON) on August 7, 2026, at 10:03 a.m. it was confirmed that the dog was residing at the facility with Resident R88. It was also discussed that there was no person-centered plan of care for the dog who had been residing at the facility.
Review of Resident R14's clinical record included the following diagnoses: end stage renal disease (happens when the kidneys no longer work well enough to meet the body's needs); hypertension (high blood pressure); heart failure ( a condition where the heart muscle doesn't pump blood as well as it should often causing blood to backs up, fluid buildup in the lungs and shortness of breath; chronic pain (pain that lasts for over three months, may be felt all the time, may come and go, can happen anywhere in an individual's body, and has countless causes), and adjustment disorder (a strong emotional or behavioral reaction to stress or trauma) with depressed mood (a mood disorder that causes a persistent feeling of sadness and loss of interest).
Review of Resident R14's clinical record revealed a note from the resident's psychologist dated April 11, 2026, at 11:40 a.m. which indicated that the resident was being seen on the above-referenced day due to impaired judgement, medical nonadherence, family stressors, and emergence of passive death wishes, impacting safety and functioning.
Continued review of the psychologist note dated April 11, 2026, indicated that Resident R14 admitted that he/she has passive death wishes. The note stated, "Midway through the session admitted occasional passive death wish but denied plan or intent".
Continued review of Resident R14's person plan of care included no person-centered plan of care related to the resident's suicide ideation to ensure appropriate care, services and to ensure that any interventions are implemented.
During an interview with the Director of Nursing (DON) on August 7, 2026, at 9:10 a.m. the psychologist's note from April 11, 2026, was reviewed, and it was discussed that there was no person-centered plan of care related to the resident's suicidal ideation.
28 Pa. Code 201.18 (b)(1) Management
28 Pa Code 211.12 (d)(5) Nursing services
28 Pa Code 211.10 (c) Resident care policies
| | Plan of Correction - To be completed: 08/31/2026
F656- Comprehensive Care Plans
On 8/7/2026, it was noted that R14 reported to psychologist on 4/11/2026 that he had occasional SI without plan or intent. Care Plan was not implemented at that time.
R88 observed on 8/6/2026 with pet residing in facility without comprehensive care plan.
Step 1- On 8/6/2026, care plan created for R88 related to facility pet.
On 8/7/2026, care plan was completed for R14 for SI.
Step 2- Any resident experiencing SI or having a pet that resides in facility have the potential to be affected.
On 8/7/2026, DON/Designee completed a 90 day audit with psychologist, for residents receiving psychology services, to determine if any residents reported SI, where noted ensured that care plans where present. No issues identified. An audit was conducted on 8/7/2026 related to facility pets care plans. No additional pets reside in the facility, no issues identified.
Step 3- To prevent future reoccurrence, Nurse Supervisors educated to comprehensive care planning related to SI and pets that reside in facility.
Step 4- To monitor and maintain ongoing compliance, DON/Designee will audit psychology progress notes for any reports of SI and care plan implementation, if noted one time weekly times ninety days. New pets residing in facility will be audited one time weekly times ninety days to ensure care plan measures are initiated.
Results of audits will be presented at monthly QAPI Committee Meeting for review and recommendations.
|
|
