§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 that addressed individual residents' needs as identified in the comprehensive assessment for two of 15 sampled residents. (Residents 20, 56)
Findings include:
Clinical record review revealed that Resident 20 had diagnoses that included legal blindness, hearing loss, difficulty walking, and an enlarged prostate. The Minimum Data Set (MDS) assessment dated February 11, 2025, noted the resident had vision difficulties, communication issues due to his impaired hearing, and continence issues. The MDS Care Area Assessment (CAA) summary noted that the resident's vision, communication, and urinary incontinence issues were to be addressed in the care plan. There was no evidence that interventions to address Resident's 20's vision, communication, and urinary incontinence were addressed in the care plan.
Clinical record review revealed that Resident 56 had diagnoses that included difficulty walking and heart failure. Resident 56's admission bowel and bladder assessment dated March 17, 2025, indicated that the resident was occasionally incontinent. The MDS CAA summary dated March 20, 2025, noted that the resident's incontinence was to be addressed in the care plan. There was no evidence that interventions to address Resident's 56's urinary incontinence was included in the current care plan.
In an interview on April 3, 2025, at 9:13 a.m., the Assistant Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the care plans.
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 04/14/2025
Plan of Correction – F0656: Develop/Implement Comprehensive Care Plan
Facility Name: Moravian Hall Square Health & Wellness
Date: 04/11/2025
Prepared By: Jessica Mateo, RN DON
Department: Nursing/Clinical Services
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Deficiency Statement:
The facility failed to develop and/or implement a comprehensive, person-centered care plan for residents, as required by F0656. Specifically, care plans were found to be missing appropriate focus areas reflective of residents' diagnoses, preferences, risks, or current conditions.
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1. Corrective Action for Residents Affected
- Responsible Party: MDS Coordinator, Interdisciplinary Team (IDT), Clinical Coordinator
- Actions Taken:
o A full audit was conducted on all residents identified in the citation.
o For each affected resident, care plans were reviewed and updated to include missing focus areas.
Resident 20: vision, communication and urinary incontinence addressed in the Care Plan.
Resident 56: Discharged
o Clinical Coordinator auditing and updating Care Plans due for review weekly.
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2. Identification of Other Residents with Potential to Be Affected
- Responsible Party: DON, MDS Coordinator
- Actions Taken:
o A facility-wide audit of care plans for all residents was initiated to identify others at risk for missing or incomplete care plans.
o Care plans for newly admitted residents, recent hospital returnees, or residents with recent changes in condition were prioritized.
o All identified deficits were corrected immediately with IDT collaboration.
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3. Systemic Changes to Prevent Recurrence
- Responsible Party: Director of Nursing, MDS Coordinator, Clinical Educator (ADON), Clinical Coordinator
- Actions Implemented:
o A revised care planning protocol was implemented to ensure that all care plans:
Are initiated within 48hrs of admission.
Are comprehensive and individualized based on each resident's assessed needs, goals, strengths, and preferences.
Include specific, measurable interventions across all disciplines.
o Interdisciplinary Team conducts weekly care plan meetings with documented follow-up and sign-off.
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4. Staff Education and Competency
- Responsible Party: Clinical Educator, DON
- Actions Taken:
o Licensed nursing staff, MDS nurses, social workers, dietary, therapy, and other IDT members were re-educated on the F0656 regulation, with focus on:
Developing individualized, person-centered care plans.
Timely updates based on changes in condition.
Documenting measurable goals and interventions.
o In-service sessions to be held on 04/22/2025 & 04/23/2025, with attendance rosters maintained.
I'm working on this and will present it during the Department Meetings (04/22/25 & 04/23/25)
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5. Quality Assurance & Monitoring
- Responsible Party: MDS Coordinator, DON
- Actions Taken:
o Ongoing monthly audits of a sample of resident care plans (minimum of 10% of census).
A new care plan review checklist was introduced to verify inclusion of all relevant focus areas (e.g., ADLs, cognition, mood, behaviors, risk factors, resident goals).
o Results of audits and any trends are reviewed in the monthly QA Committee meetings.
o Additional staff education or system changes will be initiated as needed based on audit findings.
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Completion Date for Full Compliance: 04/23/2025
✅ CARE PLAN REVIEW CHECKLIST
Resident Name: ____________________________
Room #: __________
Review Date: __________
Reviewer: ____________________________
________________________________________
🔍 Resident Identification & Person-Centered Information
- Resident's diagnoses accurately reflected
- Preferences, values, routines, and goals identified
- Resident/representative involved in care plan development
- Cultural/spiritual considerations included (if applicable)
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🧠 Cognition & Communication
- Cognitive status addressed (e.g., memory loss, dementia)
- Communication limitations/interventions included
- Safety risks related to cognition addressed (e.g., elopement, confusion)
________________________________________
🧍 Activities of Daily Living (ADLs) / Functional Status
- Current ADL performance and assistance needs addressed
- Mobility and fall prevention interventions included
- Restorative nursing/therapy goals (if applicable) reflected
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❤️ Medical & Clinical Conditions
- All active diagnoses represented (e.g., CHF, COPD, Diabetes)
- Vital signs and lab monitoring included (if needed)
- Pain management plan individualized and up-to-date
- Infection control/prevention strategies listed (if relevant)
- Medication-related risks addressed (e.g., anticoagulants, psychotropics)
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🪑 Skin Integrity
- Pressure injury risk addressed (e.g., Braden Score)
- Wound care interventions included (if applicable)
- Preventive skin care interventions documented
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🍽️ Nutrition & Hydration
- Diet type, texture, and feeding assistance needs included
- Weight loss/gain or swallowing issues addressed
- Nutritional supplements/monitoring documented
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💬 Mood, Behavior & Psychosocial Well-being
- Depression, anxiety, or mood issues addressed (if present)
- Behavioral concerns included (e.g., aggression, wandering)
- Psychotropic medication use addressed with monitoring
- Interventions are person-specific and non-pharmacological when possible
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👥 Social Services & Activities
- Resident preferences for activities included
- Social isolation, grief, or family dynamics considered
- Discharge planning goals (short-term rehab residents) identified
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🩺 Special Services / Treatments
- Therapy services included (PT/OT/ST with goals)
- Dialysis, trach care, oxygen, or other complex treatments included
- Advance Directives/Code Status clearly documented
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📋 Care Plan Structure & Timeliness
- Problem statements are individualized and relevant
- Goals are measurable, time-bound, and resident-specific
- Interventions are specific, actionable, and reflect current condition
- Reviewed/revised with each MDS assessment and significant change
- Care plan updated within 7 days of MDS completion
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🧑⚕️ Interdisciplinary Input
- Input from nursing, therapy, dietary, social services, and activities included
- Evidence of IDT meetings and care plan conference notes
- Resident and/or representative participation documented
________________________________________
✍️ Signatures
Reviewer Name & Title: ___________________________________
Date: ____________________________
Additional Notes/Follow-Up Needed:
________________________________________
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