§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 interview and record review it was determined that the facility failed to hold care plan meetings with the required members of the interdisciplinary team for one out of eight residents reviewed (Resident 9).
Findings include:
Review of Resident 9's quarterly MDS assessment (Minimum Data Set a mandatory assessment of resident care needs and medical condition) dated May 13, 2026, revealed Resident 9 was cognitively intact and their own representative. Resident 9 was totally dependent on facility staff to complete activities of daily living and dependent on facility staff for mobility. Resident 9 was totally dependent on facility staff to get out of bed.
Review of clinical records revealed that Resident 9 had quarterly MDS assessments on May 13, 2026, February 13, 2026, September 5, 2025, and a significant change (a decline or improvement affecting multiple health areas and requiring an interdisciplinary care-plan revision) MDS assessment on November 14, 2025. Further review of clinical records failed to reveal that an interdisciplinary care plan meeting occurred after those assessments or that the resident had been invited to any care plan meetings or interdisciplinary team meetings.
Interview with Resident 9 on March 24, 2026, at approximately 11:00 a.m. revealed that Resident 9 did not participate in care plan meetings because "since I can't get out of bed, I can't attend."
Interview with the Licensed Clinical Social Worker on June 25, 2026, at approximately 11:35 a.m. revealed that care plan meetings had not been held on a regular basis.
Review of the nurse practitioner encounter notes dated January 6, 2026, revealed that the reason for the encounter was "annual comprehensive evaluation". Outcome of the encounter was shared with Resident 9, the RN (Registered Nurse) unit manager, physical therapy, Resident 9's emergency contact, Resident 9's primary care physician via email, and the cardiologist. There was no evidence that members of the social work, behavioral health, activities, or dietary team were included in the outcomes of the encounter.
Review of encounter notes dated March 27, 2026, revealed that the reason for the encounter was "warmth, and erythema (redness) of rt (right) leg." Outcome of the encounter was communicated to the primary care provider and the RN unit manager. There was no evidence that members of the social work, behavioral health, activities, or dietary team were included in the outcomes of the encounter.
Review of encounter notes dated April 17, 2026, revealed that the reason for the encounter was "routine follow up of chronic medical conditions." Outcome of the encounter was communicated to Resident 9's emergency contact, the primary care provider, the LPN (licensed practical nurse), the RN unit manager, occupational and physical therapy, behavioral health, wound team, and pulmonologist. There was no evidence that members of the social work, activities, or dietary team were included in outcomes of the encounter.
Interview with the Director of Nursing on June 26, 2026, at approximately 10:30 a.m. revealed that Resident 9 was under the care of a nurse practitioner who was having their own interdisciplinary team meetings in place of care plan meetings with the facility interdisciplinary team.
28 Pa. Code 211.12(d)(5) Nursing services.
| | Plan of Correction - To be completed: 08/04/2026
1. Resident #9 had an Interdisciplinary Care Plan Meeting on 7/7/2026.
2. Social Worker/designee will complete an initial audit on current residents who had a quarterly MDS completed in the last 14 days to determine if an Interdisciplinary Care Plan Meeting was held. If residents are identified that no Interdisciplinary Care Plan Meeting was held one will be completed.
3.Social workers were re-educated by Market Social Work Lead on Care Plan Timing, Revisions and Residents are to be scheduled for an Interdisciplinary Care Plan Meeting based on their Quarterly MDS Assessment Date.
4. Social Worker/designee will complete weekly random audits x 12 weeks for 3 residents who had a quarterly MDS completed to confirm that the Interdisciplinary Care Plan Meetings were conducted
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
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