§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:
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to the resident and/or representative for five of five residents reviewed (Residents R2, R6, R9, R10, and R13).
Findings include:
Review of facility policy entitled "Care Plans Baseline" dated 11/4/25, revealed that "A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight hours of admission." The policy further stated "The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: Initial goals based on admission orders and discussion with the resident/representative, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable." The policy further stated that "The resident and/or representative are provided a written summary of the baseline care plan," and "provision of the summary to the resident and/or representative is documented in the medical record."
Resident R2's clinical record revealed an admission date of 8/2/25, with diagnoses the included Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), Stroke (occurs when blood flow to the brain is blocked or a blood vessel inside or on the surface of the brain bursts causing brain cells to die often times leading to permanent disabilities), and Diabetes (a health condition caused by the body's inability to produce enough insulin).
Resident R2's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
Resident R6's clinical record revealed an admission date of 4/25/25, with diagnoses that included Diabetes, Benign Prostatic Hyperplasia (BPH a noncancerous enlargement of the prostate gland, which can result in frequent urination, difficulty starting or stopping urination and a weak urine stream), and Atrial Fibrillation (A-Fib irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications).
Resident R6's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
Resident R9's clinical record revealed an admission date of 11/6/25, with diagnoses that included Atrial Fibrillation, Dementia (loss of cognitive functioning affecting a person's memory and behaviors), and Diabetes.
Resident R9's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
Resident R10's clinical record revealed an admission date of 11/14/25, with diagnoses that included Diabetes, Atrial Fibrillation, and Anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone).
Resident R10's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
R13's clinical record revealed an admission date of 8/20/25, with diagnoses that included Parkinson's Disease (a movement disorder of the nervous system that may result in tremors, stiffness, slowing of movement, and trouble with balance that worsens over time), Benign Prostatic Hyperplasia, and Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn).
Resident R13's clinical record lacked evidence that a baseline care plan was initiated and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
During an interview on 12/3/25, at 3:09 p.m. the Nursing Home Administrator confirmed that the clinical records for Residents R2, R6, R9, R10, and R13 lacked evidence that a baseline care plan was initiated, and/or a summary of the baseline care plan and order summary were provided to the resident and/or his/her representative.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.10(c) Resident care plan
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 01/31/2026
Baseline care plans were completed and reviewed for accuracy compliance for residents R2, R6, R9, R10 and R13. NUrsing Home Administrator (NHA_ and Director of Nursing (DON) provided Education on the policy and process of completing baseline care plans has been provided to members of the Interdisciplinary team (IDT Team) IDT team will review all residents residing in the facility to ensure they have a detailed, appropriate baseline care plan. Upon admission a baseline care plan will be started by the clinical care team. From there it will be transferred to the social services department whom will collaborate with the appropriate departments and review & develop the baseline care plan with the resident and/ or resident representative during the initial care plan process. The resident and or family will be involved in the baseline care-plan process and given a copy upon completion of the initial 48 hour meeting. Nursing Home Administrator (NHA), Director of Nursing (DON) or designee will audit fifty percent of new admissions from 12/10/2025 to 01/31/2026. This deficient practice has been identified as a performance improvement plan in in Quality Assurance Performance Improvement and will be monitored for accuracy. The purpose of the audit is to ensure the baseline care-plan was developed within 48 hours of admission and provided to the resident and/ or their responsible party.
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