In October 2016, the final rule revised the Medicare and Medicaid requirements of participation for nursing homes. There was new language in the definition of person-centered care plan, which was to focus on the resident as the locus of control to support the resident in making their own choices and to allow them control over their daily lives.

The facility’s responsibility was to focus on verbal and non-verbal communication, identify what is important to the resident in daily routines and activities, and to understand the resident’s life prior to admission. The new requirements at §483.10(c) Planning and Implementing Care (F552/553) described the following resident rights:

  • Right to be informed in advance of risks and benefits of proposed care and treatment
  • Right to identify individuals to be included in care planning
  • Right to request meetings or revisions to the care plan
  • Right to establish expected goals and outcomes
  • Right to see the care plan and sign after any significant changes
  • Right to be provided with choices and the facility must honor those choices
  • Right to preferences and the facility must honor those preferences
  • Right to exercise control

The following regulations were also put into place:

  • F655—Baseline Care Plan, Person-Centered, Initial Goals, and Provide a Summary to Resident and Representative (if applicable).
  • F656—Comprehensive Person-Centered Care Plan which includes Person-Centered, Consistent with Resident Rights, Developed with Resident and Representative, Resident Goals for Admission and Discharge, and Desired Outcomes; and
  • F657—Comprehensive Person-Centered Care Plan, which is to be prepared by the interdisciplinary team, resident and representative (if applicable).

All these changes caused confusion to the intent and timing of the regulation for the baseline care plan and the baseline summary. Even today, there are multiple questions and survey citations around the timing of the baseline care plan and summary.

Baseline Care Plan (F655)

The intent of the baseline care plan is to promote continuity of care and communication among nursing home staff, increase resident safety, safeguard against adverse events that are most likely to occur right after admission and to identify needs of supervision, behavioral interventions, and assistance with activities of daily living. Per the regulation at §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. This means if a resident is admitted Friday at 5:30 pm, the baseline care plan should be written by 5:30 pm Sunday. There is no exception for weekends, holidays or night admissions.

The baseline care plan must—(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

The baseline care plan must also include:

  • Instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care,
  • Necessary information to properly care for each resident immediately upon their admission,
  • Resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk,
  • Needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary.
  • A balance between conditions and risks affecting the resident’s health and safety, and what is important to them.

Facilities that continue to have nursing only complete 4-5 routine care plans on every admission do not meet the requirements for a baseline care plan.

The care plan is unique and focuses on the resident as the center of control. It supports each resident allowing them to make his or her own choices. The interdisciplinary team should make every effort to understand what each resident is communicating—verbally and nonverbally—identifying what is important to each resident regarding daily routines and preferred activities, and understanding the resident’s life before they come to reside in the nursing home. Because the baseline care plan must reflect the resident’s stated goals and objectives and include interventions that address current needs, check-off-cookie-cutter baseline care plans do not meet the intent of the regulation. They 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.

The regulations at §483.21(a)(2) state,

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).

Paragraph (b) is the Comprehensive Care Plan and Paragraph (b)(2)(i) means the care plan must be developed within 7 days after completion of the comprehensive assessment.

If the facility is replacing the baseline care plan with a comprehensive care plan, then both criteria above must be met. Per regulations and survey guidance, caution is required.

If the facility completes a comprehensive care plan instead of the baseline care plan, the surveyors are to review the requirements of the comprehensive care plan at §483.21(b). If the care plan does not meet the requirements of §483.21(b), cite at the appropriate corresponding tag(s):

  • F656 Develop Comprehensive Care Plan
  • F657 Care Plan Timing and Revision
  • F658 Services Provided Meet Professional Standards
  • F659 Qualified Persons

Baseline Summary (F655)

At §483.21(a)(3), regulations state,

The facility must provide the resident and their representative, if applicable, with a summary of the baseline care plan that includes but is not limited to:

(i) Initial goals for 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 the personnel acting on behalf of the facility, and
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Timing

The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by completion of the comprehensive care plan (V0200C2), not within 48 hours.

Providing the baseline summary within 48 hours of admission has been the area of confusion for facilities and surveyors. LW Consulting, Inc. has received emails from facilities stating that when surveyors come on-site, they are asking about documentation to support that the baseline summary was provided within 48 hours. Per the regulation, as stated above, the baseline summary must be provided to the resident and representative, if applicable, by the completion of the comprehensive care plan. When a resident is newly admitted to the facility, the admission assessment and CAAS must be completed within 14 days of admission. The comprehensive care plan decisions must be completed within 7 days from the completion of the Minimum Data Set (MDS) and CAAs. The date on the MDS is located at (V0200C2). 

The regulations state that facilities may provide the resident with a copy of the baseline care plan as the summary as long as it meets all of the above stated criteria. The problem that LW Consulting, Inc. has identified during audits is that not all criteria are being met. For example, the care plan generally does not list the medications the resident is receiving. It is important for facilities to consider providing the resident with a copy of the orders or the Medication Administration Record (MAR) which contains the listing of the medications the resident is receiving.

Given that the baseline care plan is developed before the comprehensive assessment, it is possible that the goals and interventions may change. If the comprehensive assessment and comprehensive care plan identify a change in the resident’s goals, or physical, mental, or psychosocial functioning—which was otherwise not identified in the baseline care plan—those changes must be incorporated into an updated summary and provided to the resident and representative, if applicable.

Proof of Providing the Baseline Summary

Surveyors will be looking for proof that the baseline care plan was completed timely and that the baseline summary was provided to the resident and representative, if applicable. Facilities have different ways of accomplishing this. Some facilities have the resident sign a form stating that they have received the baseline care plan and summary. Some make copies of what is provided to the resident and representative and place those copies in the hard chart with a note in the clinical record. Other facilities do not have documentation to support that the baseline care plan and summary were provided to the resident and representative, if applicable. These facilities are the ones that receive a F655, F656 and F657 citation. So, make sure you have proof of providing the baseline care plan and summary in your medical record.

Remember, the 48-hour deadline is not 2 days, it is 48 hours. See an example below. Make sure late Friday night and weekend admissions meet this regulation.