§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.
§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).
§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
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Observations:
Findings include:
Review of facility policy 'Comprehensive person-centered care plans ' revised December 2016, indicates that "Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. "
Review of Resident R1's admission interim care plan, completed on August 18, 2025, at 3:06 pm, indicated the resident was incontinent of bowel and bladder. The resident required total dependance for personal hygiene, toilet use and bathing.
Review of R1's care plan revealed no evidence of goals or interventions related to incontinence care.
Review of Resident R6's clinical record revealed that at times, the resident required substantial/maximal assistance with toileting hygiene and was dependent: "helper does all of the effort. Resident does none of the effort to complete activity. Or, the assistance of two or more helpers is required for the resident to complete the activity."
Further review of Resident R6 's clinical record revealed that at times, she was incontinent of bowel and bladder.
Review of Resident R6's care plan indicates no evidence of goals or interventions related to incontinence care.
Review of Resident R7 's ' functional abilities and goals - admission, ' completed on October 13, 2025 at 6:29 pm, indicated the resident she required substantial/maximal assistance with toileting hygiene; further review of clinical record revealed the resident was incontinent of bladder function.
Review of Resident R7 's care plan revealed no evidence of goals or interventions related to incontinence care.
Review of Resident R8 's 'interim care plan' completed on October 22, 2025 at 9:27 pm, revealed the resident required total dependance for personal hygiene, toilet use, and was incontinent of bladder and bowel function.
Review of Resident R8 's care plan revealed no evidence of goals or interventions related to incontinence care.
Review of Resident R9's ' functional abilities and goals - admission, 'completed on October 25, 2025, at 12:35 pm, revealed the resident was dependent for toileting hygiene; further review of clinical record revealed Resident R9 was incontinent of bladder function.
Review of Resident R9 's care plan revealed no evidence of goals or interventions related to incontinence care.
Interview with Nursing Home Administrator and Director of Nursing on October 29, 2025 at 2:30 pm confirmed the above findings.
28 Pa Code 211.10(d) Resident Care Policies
| | Plan of Correction - To be completed: 01/06/2026
Step 1: Care plans for Residents R1, R6, R7, R8, and R9 were updated to include appropriate goals and interventions related to incontinence care.
Step 2: Resident care plans were reviewed to ensure incontinence care is addressed when clinically indicated.
Step 3: Nursing staff, care plan nurses, and unit managers were educated on incorporating incontinence goals and interventions into care plans based on assessments and changes in condition.
Step 4: Five resident care plans will be Audited once per week for one month, twice per month for one month, and once per month for one month to ensure incontinence care is correctly represented.
Step 5: Findings from these audits will be reported to the QAPI Committee monthly for six months.
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