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Requirements of Participation: Baseline Care Plans

Avatar Rita Labrado
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The Requirements of Participation for Long Term Care Facilities was released October 4, 2016.  The regulations are phased in over 3 years as follows:

  • Phase 1: 11/28/2016
  • Phase 2: 11/28/2017
  • Phase 3: 11/28/2019

The regulation pertaining to baseline care plans is effective in phase 2. This requirement has become a hot topic among our clients recently. The specific regulation reads as follows:

§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.

 

This means that effective 11/28/2017 nursing homes must complete and implement a baseline care plan within 48 hours of the resident’s admission. In addition, a summary of the baseline care plan must be provided to the resident and/or their representative by the completion of the comprehensive care plan.

The baseline care plan requirement should not be a big change for facilities that have an interim care plan process already in place. The interim care planning requirements to cover a resident’s immediate needs have been in place for years.  The change is in the level of detail in the requirements.  If a facility has NOT had a solid interim care planning process in place, then these changes will require additional work.

On June 30, the Centers for Medicare & Medicaid Services released an advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual, offering some important details about the baseline care plan implementation requirements in F-tag 655.

INTENT §483.21(a)

Completion and implementation of the baseline care plan within 48 hours of a resident’s admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan.


GUIDANCE §483.21(a)

Nursing homes are required to develop a baseline care plan within the first 48 hours of admission which provides instructions for the provision of effective and person-centered care to each resident. This means that the baseline care plan should strike a balance between conditions and risks affecting the resident’s health and safety, and what is important to him or her, within the limitations of the baseline care plan timeframe.

 Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident’s life before coming to reside in the nursing home.

 The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Baseline care plans are required to address, at a minimum, the following:

  • Initial goals based on admission orders.
  • Physician orders.
  • Dietary orders.
  • Therapy services.
  • Social services.
  • PASARR recommendation, if applicable.

The baseline care plan must reflect the resident’s stated goals and objectives, and include interventions that address his or her current needs. It must be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident’s immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff must implement the interventions to assist the resident to achieve care plan goals and objectives.

Facilities may complete a comprehensive care plan instead of the baseline care plan. In this circumstance, the completion of the comprehensive care plan will not override the RAI process, and must be completed and implemented within 48 hours of admission and comply with the requirements for a comprehensive care plan at §483.21(b), with the exception of the requirement at (b)(2)(i) requiring the completion of the comprehensive care plan within 7 days of completion of the comprehensive assessment. If a comprehensive care plan is completed in lieu of the baseline care plan, a written summary of the comprehensive care plan must be provided to the resident and resident representative, if applicable, and in a language that the resident/representative can understand.

 

Some recommendations for consideration:

  1. Consider interdisciplinary participation in care plan development
    Many facilities have assigned care planning responsibilities to either the MDS coordinator or the Admission coordinator.  This may not be appropriate if they do not work weekends. Educate all members of the IDT team on the need for baseline care planning and their responsibility to contribute within the 48 hour timeframe.
  1. Review your admission assessments
    This is an opportunity to review and enhance nursing, dietary, social service and any other IDT assessments to be sure the appropriate information is collected to help build the care plan
  1. Consider an interim meeting with the resident and their representatives to discuss the resident goals for their stay
    Rather than wait until the comprehensive care plan is complete use the opportunity to meet with the resident and their representative to gather the information needed in the baseline care plan to reflect the resident’s (person-centered) goals.
  1. Be sure to incorporate discharge planning
    Discharge planning should be started at admission.  This will help to identify the resident specific goals to include in the baseline and eventually comprehensive care plan.
  1. Care plans are NEVER done
    The care plan should reflect the changes that occur over time as the resident progresses or declines and should reflect their personal goals regarding the changes.
  2. Practice!
    Do not wait until the last minute to implement a new process. Start now to help iron out kinks and clarify responsibilities.  You can then review and revise the process as appropriate so you have a well-oiled plan in place by 11/28/2017.

    Recommended areas to consider in baseline care plan development:
     - Cognitive functioning
     - Vision
     - Hearing
     - Communication
     - Mobility
     - ADL Functioning
     - Dressing
     - Grooming
     - Bathing
     - Oral/Dental Care
     - Eating
     - Nutrition
     - Elimination
     - Bed Routine
     - Sleep
     - Psycho-Social
     - Safety

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