Long term Care IDT members are you aware of survey regulations related to Baseline vs Comprehensive Care plans? When to review with resident/responsible party and who should be at the care plan review?

We are all aware that a MDS assessment should be completed by day 14 of a residents admission and a comprehensive care plan be developed by day 21 of the residents stay. There is also a requirement that a baseline care plan be developed and reviewed with the family within 48 hours of admission.

This sounds fairly simple but when you review the specifics of the regulations it can leave facilities at risk for surveys citations.

See the specifics below as copied directly from pages 234-262 of Appendix PP State Operations Manual.pdf

0. F655
   (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)§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 aresident 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 (exceptingparagraph (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 actingon behalf of the facility.
   (iv) Any updated information based on the details of the comprehensive care plan, asnecessary.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.

If the facility completes a comprehensive care plan instead of the baseline care plan, 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 Care Plan Summary

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. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include:

o Initial goals for the resident;
o A list of current medications and dietary instructions, and
o Services and treatments to be administered by the facility and personnel acting on

behalf of the facility;
The format and location of the summary is at the facility’s discretion, however, the medical record must contain evidence that the summary was given to the resident and resident representative, if applicable. The facility may choose to provide a copy of the baseline care plan itself as the summary, as long as it meets all of the requirements of the summary.

Given that the baseline care plan is developed before the comprehensive assessment, it is possible that the goals and interventions may change. In the event that the comprehensive assessment and comprehensive care plan identified 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 provided to the resident and his or her representative, if applicable.

As the resident remains in the nursing home, additional changes will be made to the comprehensive care plan based on the assessed needs of the resident, however, these subsequent changes will not need to be reflected in the summary of the baseline care plan. Once the comprehensive care plan has been developed and implemented, and a summary of the updates given to the resident, the facility is no longer required to revise/update the written summary of the baseline care plan. Rather, each resident will remain actively engaged in his or her care planning process through the resident’s rights to participate in the development of, and be informed in advance of changes to the care plan; see the care plan; and sign the care plan after significant changes. Refer to §483.10(c) for guidance related to Resident Rights and Facility Responsibilities regarding Planning and Implementing Care.

INVESTIGATIVE SUMMARY AND PROBES §483.21(a)

• Use the Critical Element (CE) Pathway associated with the issue under investigation, or if there is no specific CE Pathway, use the General CE Pathway, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the facility’s requirement develop and implement a Baseline Care Plan. If systemic concerns are identified with Baseline Care Plans, use the probes below to assist in your investigation.
• Was the baseline care plan developed and implemented within 48 hours of admission to the facility?
• Does the resident’s baseline care plan include: o The resident’s initial goals for care;

o The instructions needed to provide effective and person-centered care that meets

professional standards of quality care;
o The resident’s immediate health and safety needs; o Physician and dietary orders;
o PASARR recommendations, if applicable; and
o Therapy and social services.

• Was the baseline care plan revised and updated as needed to meet the resident’s needs until the comprehensive care plan was developed?
• If the resident experienced an injury or adverse event prior to the development of the comprehensive care plan, should the baseline care plan have identified the risk for the injury/event (i.e., if risk factors were known or obvious)?
• Did the facility provide the resident and his or her representative, if applicable, with a written summary of the baseline care plan that contained at least, without limitation: o Initial goals of the resident;
  o A summary of current medications and dietary instructions;o Services and treatments to be provided or arranged by the facility and personnel acting on behalf of the facility; ando Any updated information based on details of the admission comprehensive assessment.F656(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)§483.21(b) Comprehensive Care Plans
  §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following —(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.

(iv)In consultation with the resident and the resident’s representative(s)—
(A) The resident’s goals for admission and desired outcomes.
(B) The resident’s preference and potential for future discharge. Facilities must

document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—

(iii) Be culturally-competent and trauma–informed.

INTENT

Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident’s medical, physical, mental and psychosocial needs.

DEFINITIONS

“Culture” is the conceptual system that structures the way people view the world—it is the particular set of beliefs, norms, and values that influence ideas about the nature of relationships, the way people live their lives, and the way people organize their world. Adopted from Substance Abuse and Mental Health Services Administration. Improving Cultural Competence.
Treatment Improvement Protocol (TIP) Series No. 59. HHS Publication No. (SMA) 14-4849.https://store.samhsa.gov/system/files/sma14-4849.pdf.

“Cultural Competency” is a developmental process in which individuals or institutions achieve increasing levels of awareness, knowledge, and skills along a cultural competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoiding stereotypes, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities.

US Department of Health and Human Services publication: A Blueprint for Advancing and Sustaining CLAS Policy and Practice at: https://www.thinkculturalhealth.hhs.gov/clas/blueprint.

“Resident’s Goal” refers to the resident’s desired outcomes and preferences for admission, which guide decision-making during care planning.

“Interventions” are actions, treatments, procedures, or activities designed to meet an objective. “Measurable” is the ability to be evaluated or quantified.

 

“Objective” is a statement describing the results to be achieved to meet the resident’s goals. “Person-centered care” means to focus on the resident as the locus of control and support the

resident in making their own choices and having control over their daily lives.

“Trauma-informed care” is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Adapted from: SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach, https://store.samhsa.gov/system/files/sma14-4884.pdf.

GUIDANCE

Through the care planning process, facility staff must work with the resident and his/her representative, if applicable, to understand and meet the resident’s preferences, choices and goals during their stay at the facility. The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. If care planning is not complete, or is inadequate, the consequences may negatively impact the resident’s quality of life, as well as the quality of care and services received.

Facilities are required to develop care plans that describe the resident’s medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. Care plans must include person-specific, measurable objectives and timeframes in order to evaluate the resident’s progress toward his/her goal(s).

Care plans must be person-centered and reflect the resident’s goals for admission and desired outcomes. 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.

Residents’ goals set the expectations for the care and services he or she wishes to receive. For example, a resident admitted for rehabilitation may have the following goal – “Receive the necessary care and services so that I may return to independent living.” Another resident may have a goal of receiving the necessary care and services to meet needs they cannot independently achieve, while maintaining as much independence as possible. And yet another resident or his or her representative, if applicable, may have a goal of receiving the necessary care and services to keep the resident comfortable and pain-free at the end of their life. Each of these examples would be supported by measurable objectives, interventions and timeframes designed to meet each specific resident goal.

Measurable objectives describe the steps toward achieving the resident’s goals, and can be measured, quantified, and/or verified. For example, “Mrs. Jones, who underwent hip replacement, will report adequate pain control (as evidenced by pain at 1-3, on a scale of 1-10) throughout her SNF stay.” Facility staff will use this objective to monitor the resident’s progress.

The comprehensive care plan must reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Interventions for the example above, related to pain, may include, but are not limited to:

• Evaluate pain level using pain scale (0-10) 45 minutes after administering pain medication;
• Administer pain medication 45-60 minutes prior to physical therapy.When developing the comprehensive care plan, facility staff must, at a minimum, use the Minimum Data Set (MDS) to assess the resident’s clinical condition, cognitive and functional status, and use of services.If a Care Area Assessment (CAA) is triggered, the facility must further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility’s rationale for deciding whether or not to proceed with care planning for each area triggered must be recorded in the medical record.There may be times when a resident risk, weakness or need is identified within the context of the MDS assessment, but may not cause a CAA to trigger. The facility is responsible for addressing these areas and must document the assessment of these risks, weaknesses or needs in the medical record and determine whether or not to develop a care plan and interventions to address the area. If the decision to proceed to care planning is made, the interdisciplinary team (IDT), in conjunction with the resident and/or resident’s representative, if applicable (§483.21(b)(2)(ii)), must develop and implement the comprehensive care plan and describe how the facility will address the resident’s goals, preferences, strengths, weaknesses, and needs.NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition to meet the resident’s needs between required RAI assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health.In some cases, a resident may wish to refuse certain services or treatments that professional staff believes may be indicated to assist the resident in reaching his or her highest practicable level of well-being or to keep the resident safe. In situations where a resident’s choice to decline care or treatment (e.g., due to preferences, maintain autonomy, etc.) poses a risk to the resident’s health or safety, the comprehensive care plan must identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the

resident and the representative, as appropriate. The facility’s attempts to find alternative means to address the identified risk/need should be documented in the care plan. See guidelines at §483.10(c)(6) (F578) for additional guidance concerning the resident’s decision to refuse treatment. Additionally, a resident’s decision-making ability may decline over time. The facility should determine how the resident’s decisions may increase risks to health and safety, evaluate the resident’s decision making capacity, and involve the interdisciplinary team and the resident’s representative, if applicable, in the care planning process.

In addition to addressing preferences and needs assessed by the MDS, the comprehensive care plan must coordinate with and address any specialized services or specialized rehabilitation services the facility will provide or arrange as a result of PASARR recommendations. If the IDT disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. The rationale should include an explanation of why the resident’s current assessed needs are inconsistent with the PASARR recommendations and how the resident would benefit from alternative interventions. The facility should also document a resident’s the resident’s preference for a different approach to achieve goals or refusal of recommended services.

Residents’ preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

The comprehensive care plan must address a resident’s preference for future discharge, as early as upon admission, to ensure that each resident is given every opportunity to attain his/her highest quality of life. This encourages facilities to operate in a person-centered fashion that addresses resident choice and preferences.

Culturally Competent Care

Cultural competency, (also known as cultural responsiveness, cultural awareness, and cultural sensitivity) refers to a person’s ability to interact effectively with persons of cultures different from his/her own. it means being respectful and responsive to the health beliefs, practices and cultural and linguistic needs of diverse population groups, such as racial, ethnic, religious or social groups (https://www.samhsa.gov/capt/applying-strategic-prevention/cultural- competence). The interventions in the resident’s care plan must reflect the individual resident’s needs and preferences and align with the resident’s cultural identity.

Trauma-Informed Care

Given the widespread nature and highly individualized experience of trauma, the utilization of trauma-informed approaches is an essential part of person-centered care. Facilities must recognize the effects of past trauma on residents and collaborate with the resident, family and friends of the resident to identify and implement individualized interventions. Interventions for trauma survivors should recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, aggression, depression, anxiety, and withdrawal or isolation from others.

Surveyors should refer to the following when investigating concerns related to culturally- competent, trauma-informed care:

• F656: For concerns related to development or implementation of culturally competent and/or trauma-informed care plan interventions;
• F699: For concerns related to outcomes or potential outcomes to the resident related to culturally-competent and/or trauma-informed care;
• F726: For concerns related to the knowledge, competencies, or skill sets of nursing staff to provide care or services that are culturally competent and trauma-informed.
• F742: For concerns related to treatment and services for resident with history of trauma and/or history of post-traumatic stress disorder (PTSD)INVESTIGATIVE PROCEDURESUse the Critical Element (CE) Pathway associated with the issue under investigation, or if there is no specific CE Pathway, use the General Critical Element Pathway, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the facility’s requirement to develop and implement a Comprehensive Care Plan. If systemic concerns are identified with Comprehensive Care Plans, use the probes below to assist in your investigationPROBES
  • Does the care plan address the goals, preferences, needs and strengths of the resident, including those identified in the comprehensive resident assessment, to assist the resident to attain or maintain his or her highest practicable well-being and prevent avoidable decline?
  • Are objectives and interventions person-centered, measurable, and do they include time frames to achieve the desired outcomes?
  • Is there evidence of resident and, if applicable resident representative participation (or attempts made by the facility to encourage participation) in developing person-centered, measurable objectives and interventions?
  • Does the care plan describe specialized services and interventions to address PASARR recommendations, as appropriate?
  • Does the care plan describe interventions that reflect the resident’s cultural preferences, values and practices?
  • For residents with a history of trauma, does the care plan describe corresponding interventions for care that are in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident? (See §483.25(m))
  • Is there evidence that care plan interventions were implemented consistently across all shifts?
  • Is there a process in place to ensure direct care staff are aware of and educated about the care plan interventions?

• Determine whether the facility has provided adequate information to the resident and, if applicable resident representative so that he/she was able to make informed choices regarding treatment and services.
• Evaluate whether the care plan reflects the facility’s efforts to find alternative means to address care of the resident if he or she has refused treatment.POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION

• F658: for concerns regarding the delivery of care within professional standards of practice.

If the surveyor identifies concerns about the resident’s care plan being individualized and person-centered, the surveyor should also review requirements at:

• Resident Rights, §483.10
• Resident assessment, §483.20
• Activities, §483.24(c)
• Nursing services, §483.35
• Food and nutrition services, §483.60
• Facility assessment, §483.70(e)
• Cultural competence and trauma-informed care, §483.25(m)
• Treatment/Services for mental/psychosocial concerns §483.40(b)(1)KEY ELEMENTS OF NON-COMPLIANCETo cite deficient practice at F656, the surveyor’s investigation will generally show that the facility failed to do one or more of the following:

• Develop and implement a care plan that:

o Is comprehensive and individualized;
o Is consistent with the resident’s goals and right to be informed and participate in

his/her treatment;
o Meets each of the medical, nursing, mental and psychosocial needs identified on the

resident’s comprehensive assessment;
o Includes measurable objectives, interventions and timeframes for how staff will meet

the resident’s needs.
• Develop and implement a care plan that describes all of the following:

o Resident goals and desired outcomes;
o The care/services that will be furnished so that the resident can attain or maintain

his/her highest practicable physical, mental and psychosocial well-being;
o The specialized services to be provided as a result of the PASARR evaluation and/or

the comprehensive assessment;
o The resident’s discharge plan and any referrals to the local contact agency;

o Refusals of care and action taken by facility staff to educate the resident and resident representative, if applicable, regarding alternatives and consequences;

o Care and services which are culturally competent and trauma-informed.

DEFICIENCY CATEGORIZATION
Examples of Level 4, immediate jeopardy to resident health and safety, include, but are not limited to:

• A resident has a known history of inappropriate sexual behaviors and aggression, but the comprehensive care plan did not address the resident’s inappropriate sexual behaviors or aggression which placed the resident and other residents in the facility at risk for serious physical and/or psychosocial injury, harm, impairment, or death.
• The facility failed to implement care plan interventions to monitor a resident with a known history of elopement attempts, which resulted in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death.
• The facility failed to identify a resident’s cultural dietary restrictions related to eating pork. After eating her dinner, upon realization that she had eaten pork, the resident began crying inconsolably and screaming that this was explicitly forbidden in her culture and faith of Islam. The resident remained tearful and inconsolable for several days, and would not eat the food provided by the facility, which resulted in weight loss and serious psychosocial harm.Examples of Level 3, actual harm that is not immediate jeopardy include, but are not limited to:
  • The CAA Summary for a resident indicates the need for a care plan to be developed to address nutritional risks in a resident who had poor nutritional intake. A care plan was not developed, or the care plan interventions did not address the problems/risks identified. The lack of interventions caused the resident to experience weight loss.
  • Lack of care plan interventions to address a resident’s anxiety, depression, and hallucinations resulted in psychosocial harm to the residentExamples of Level 2, no actual harm, with potential for than more than minimal harm, that is not immediate jeopardy, include, but are not limited to:
    • During the comprehensive assessment, a resident indicated a desire to participate in particular activities, but the comprehensive care plan did not address the resident’s preferences for activities, which resulted in the resident complaining of being bored, and sometimes feeling sad about not participating in activities he/she expressed interest in attending.
    • An inaccurate or incomplete care plan resulted in facility staff providing one staff to assist the resident, when the resident required the assistance of two staff, which had the potential to cause more than minimal harm.

An example of Level 1, no actual harm with potential for no more than a minor negative impact on the resident, includes, but is not limited to:

For one or more care plans, the staff did not include a measurable objective, which resulted in no more than a minor negative impact on the involved residents.

F657
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§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.

INTENT of §483.21(b)(2)

To ensure the timeliness of each resident’s person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care.

DEFINITIONS
“Non-physician practitioner (NPP)” is a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA).

GUIDANCE §483.21(b)(2)

Facility staff must develop the comprehensive care plan within seven days of the completion of the comprehensive assessment (Admission, Annual or Significant Change in Status) and review and revise the care plan after each assessment. “After each assessment” means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) as required by §483.20, except discharge assessments. For newly admitted residents, the comprehensive care plan must be completed within seven days of the completion of the comprehensive assessment and no more than 21 days after admission.

As used in this requirement, “Interdisciplinary” means that professional disciplines, as appropriate, will work together to provide the greatest benefit to the resident. It does not mean that every goal must have an interdisciplinary approach. The mechanics of how the interdisciplinary team (IDT) meets its responsibilities in developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written communication) is at the discretion of the facility. In instances where an IDT member participates in care plan development, review or revision via written communication, the written communication in the medical record must reflect involvement of the resident and resident representative, if applicable, and other members of the IDT, as appropriate.

The IDT must, at a minimum, consist of the resident’s attending physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff, and to the extent possible, the resident and resident representative, if applicable. If the attending physician is unable to participate in the development of the care plan,, he/she may delegate participation to an NPP who is involved in the resident’s care, to the extent permitted by state law, or arrange alternative methods of providing input in the development and revision of the care plan, such as one-on-one discussions, videoconferencing and conference calls with the IDT.

The determination of other appropriate staff or professionals participation in the IDT should be based on the physical, mental and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, social workers, and other professionals, such as developmental disabilities specialists or spiritual advisor. Involvement of other individuals is dependent upon resident request and/or needs.

Each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment.

Facility staff have a responsibility to assist residents to engage in the care planning process, e.g., helping residents and resident representatives, if applicable understand the assessment and care planning process; holding care planning meetings at the time of day when the resident is functioning best; planning enough time for information exchange and decision making; encouraging a resident’s representative to participate in care planning and attend care planning conferences.

The facility must provide the resident and resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation. Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing.

Facilities are expected to facilitate the residents’ and if applicable, the resident representatives’ participation in the care planning process. There are limited circumstances in which the inclusion of the resident and/or resident representative may not be practicable (or feasible). An

example may be the case of a severely cognitively impaired resident who is unable to understand or participate in care plan development, and the resident’s representative does not respond to facility attempts to make contact. If the facility determines that the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons, including the steps the facility took to include the resident and/or resident representative, must be included in the medical record.

While Federal regulations at §483.10(c) affirm the resident’s right to participate in care planning, request and/or refuse treatment, the regulations do not create the right for a resident or resident representative, if applicable, to demand that the facility use specific medical interventions or treatments that the facility deems not medically necessary and/or reasonable.

The resident’s care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health.

For concerns related to the resident’s rights to participate in planning and implementing his or her care, see requirements at §483.10(c).

INVESTIGATIVE SUMMARY AND PROBES §483.21(b)(2)

Use the Critical Element (CE) Pathway associated with the issue under investigation, or if there is no specific CE Pathway, use the General Critical Element Pathway, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the facility’s requirement for timely completion and IDT and resident involvement in the development of the Comprehensive Care Plan. If systemic concerns are identified with timeliness and IDT/resident involvement in the development of Comprehensive Care Plans, use the probes below to assist in your investigation.

• Was a comprehensive plan of care developed within seven days of completion of the resident’s comprehensive assessment?
• Is there evidence of participation in the care planning process by required IDT members?
• Ask required members of the IDT how they participate in the development, review andrevision of care plans.
• Based on the resident’s goals and needs, were other appropriate staff or professionals’expertise utilized to develop a plan to improve the resident’s functional abilities? For example:

a. Did an occupational therapist recommend needed adaptive equipment or a speech therapist provide techniques to improve swallowing ability?

b. Did the dietitian and speech therapist determine the optimum textures and consistency for the resident’s food that is nutritionally adequate and compatible with the resident’s oropharyngeal capabilities and food preferences?

• Is there evidence of attending physician involvement in development of the care plan (e.g., presence at care plan meetings, conversations with team members concerning the care plan, conference calls, written communication)?
• How do staff make an effort to schedule care plan meetings at the best time of the day for residents and if applicable, the resident representatives?
• How do staff make the care plan process understandable to the resident and resident representative, if applicable?
• Ask the resident and resident representative, if applicable if he or she actively participates in the care planning process? If not, what have been the barriers to participation?
• Ask the resident and if applicable, the resident representative if he or she has requested the participation of additional individuals care planning process. If so, was the request respected?
• In what ways does staff involve the resident and if applicable, the resident representative in care planning? If staff determine that the resident and/or resident representative involvement in care planning is not practicable, is the reason and the steps the facility took to include the resident and/or resident representative documented in the medical record?
• Is there evidence that the care plan is evaluated for effectiveness and revised following each required assessment, except discharge assessments, and as needed?DEFICIENCY CATEGORIZATION
  An example of Level 4, immediate jeopardy to resident health or safety, includes, but is not limited to:

• The resident’s care plan was not revised following a significant change assessment which identified an occurrence of resident-to resident sexual abuse, placing the abused resident and other residents at risk for serious injury, impairment or death.

An example of Level 3, actual harm that is not immediate jeopardy includes, but is not limited to:

• The facility failed to develop the comprehensive care plan within seven days of completion of the comprehensive assessment. This resulted in the resident sustaining a laceration requiring stitches due to a fall because appropriate fall prevention interventions were not implemented timely.

Examples of Level 2, no actual harm with potential for than more than minimal harm that is not immediate jeopardy, include, but are not limited to:

• Residents and their representatives, if applicable, are not routinely invited to participate in care planning. While the resident did not experience an actual decline in physical, mental, or psychosocial functioning and continued to meet goals established on the care plan, the care plan goals did not show evidence of resident and if applicable, the resident representative input, having the potential for more than minimal harm.
• Direct-care staff were not made aware of revisions to the resident’s care plan by the IDT for three days to assist the resident in brushing his teeth. This resulted in staff not

assisting the resident with brushing his teeth for three days, and the resident did not suffer actual harm.

Examples of Level 1, no actual harm with potential for no more than a minor negative impact on the resident, include, but are not limited to:

• Care plan was not reviewed by the IDT after the resident’s quarterly assessment indicated a minor change in the resident’s status.
• A required member of the IDT did not participate in development of the resident’s care plan, which had no more than a minor negative impact to the resident.F658(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)§483.21(b)(3) Comprehensive Care Plans
  The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—(i) Meet professional standards of quality.INTENT §483.21(b)(3)(i)The intent of this regulation is to assure that services being provided meet professional standards of quality.GUIDANCE §483.21(b)(3)(i)“Professional standards of quality” means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include:

• Current manuals or textbooks on nursing, social work, physical therapy, etc.
• Standards published by professional organizations such as the American DieteticAssociation, American Medical Association, American Medical Directors Association, American Nurses Association, National Association of Activity Professionals, National Association of Social Work, etc.
• Clinical practice guidelines published by the Agency for Healthcare Research and Quality.
• Current professional journal articles.NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI assessments should be addressed at §483.35 Nursing Services, F726 (competency and skills to

identify and address a change in condition), and the relevant outcome tag, such as §483.12 Abuse, §483.24 Quality of Life, §483.25 Quality of Care, and/or §483.40 Behavioral Health.

NOTE: CMS is aware of situations where practitioners have potentially misdiagnosed residents with a condition for which antipsychotics are an approved use (e.g., new diagnosis of schizophrenia) which would then exclude the resident from the long-stay antipsychotic quality measure. For these situations, determine if non-compliance exists related to the practitioner not adhering to professional standards of quality for assessing and diagnosing a resident. This practice may also require referrals by the facility and/or the survey team to State Medical Boards or Boards of Nursing.

PROCEDURES AND PROBES §483.21(b)(3)(i)

There is no requirement for the surveyor to cite a reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the standard of practice that has not been followed related to care and services provided within professional scopes of practice, such as failure of nursing staff to assess a change in the resident’s condition. However, in cases where the facility provides a reference supporting a particular standard of practice for which the surveyor has concerns, the surveyor must provide evidence that the standard of practice the facility is using is not up-to-date, widely accepted, or supported by recent clinical literature. Such evidence should include a citation for the reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the current standard of practice from which facility deviated.

If a negative or potentially negative resident outcome is determined to be related to the facility’s failure to meet professional standards and the team determines a deficiency has occurred, it should also be cited under the appropriate quality of care or other relevant requirement. For example, if a resident develops a pressure injury because the facility’s nursing staff failed to provide care in accordance with professional standards of quality, the team should cite the deficiency at both F658 and F686 (Skin Integrity).

• Do the services provided or arranged by the facility, as outlined in the comprehensive care plan, reflect accepted standards of practice?
• Are the references for standards of practice, used by the facility, up to date, and accurate for the service being delivered?KEY ELEMENTS OF NONCOMPLIANCE:
  To cite deficient practice at F658, the surveyor’s investigation will generally show that the facility did one or more of the following:

• Provided or arranged for services or care that did not adhere to accepted standards of quality;
• Provided a service or care when the accepted standards of quality dictate that the service or care should not have been provided;

• Failed to provide or arrange for services or care that accepted standards of quality dictate should have been provided.

F659

(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22)

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—

(ii) Be provided by qualified persons in accordance with each resident’s written plan of care.

GUIDANCE

The facility must ensure that services provided or arranged in accordance with the resident’s plan of care are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity. This includes proper licensure or certification, if required.

INVESTIGATIVE PROCEDURES AND PROBES
NOTE: Provision of services by qualified individuals would be cited here, but implementation

of the care plan would be cited in F656.

• Are the services identified in the comprehensive care plan being provided by qualified persons?
• Do staff assigned to the resident have the skills, experience and knowledge to provide care and services that meet the resident’s needs?DEFICIENCY CATEGORIZATION
  An example of Level 4, immediate jeopardy to resident health or safety includes, but is not limited to:

• The facility had no qualified staff on duty knowledgeable or competent in how to care for a resident with a tracheostomy, posing a risk for serious injury, harm, impairment or death for the resident.

An example of Level 3, actual harm that is not immediate jeopardy includes, but is not limited to:

• The facility utilized a staff member who was not qualified to draw a resident’s blood, according to the resident’s care plan, resulting in the resident sustaining extensive bruising, swelling, pain and decreased ability to use the arm after the blood draw

An example of Level 2, no actual harm with potential for than more than minimal harm that is not immediate jeopardy includes, but is not limited to:

• The facility failed to ensure staff were qualified to perform blood pressure (BP) readings. During survey, staff were observed taking and reporting resident BPs that were abnormal. After further investigation, it was determined that staff were using the incorrect size BP cuff, yielding inaccurate BP readings, resulting in the potential for more than minimal harm.

Non-compliance with this regulation places the resident at risk for more than minimal harm. Therefore, Severity Level 1 does not apply for this regulatory requirement.

F660
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility’s discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and—

(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.

(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.

(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.

(iv) Consider caregiver/support person availability and the resident’s or caregiver’s/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.

(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.

(vi) Address the resident’s goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving

information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility

must document any referrals to local contact agencies or other appropriate

entities made for this purpose.
(B) Facilities must update a resident’s comprehensive care plan and discharge plan,

as appropriate, in response to information received from referrals to local

contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must

document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a

HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality

measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences.

(ix) Document, complete on a timely basis based on the resident’s needs, and include in the clinical record, the evaluation of the resident’s discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident’s representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident’s discharge or transfer.

INTENT §483.21(c)(1)

This requirement intends to ensure that the facility has a discharge planning process in place which addresses each resident’s discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan.

DEFINITIONS §483.21(c)(1)
“Discharge Planning”: A process that generally begins on admission and involves identifying each resident’s discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident’s stay to ensure a successful discharge.

“Home Health Agency (HHA)”: a public agency or private organization (or a subdivision of either) which is primarily engaged in providing skilled nursing services and other therapeutic services in the patient’s home and meets the requirements of sections 1861(o) and 1891 of the Social Security Act.

“Inpatient Rehabilitation Facility (IRF)”: are freestanding rehabilitation hospitals or rehabilitation units in acute care hospitals that serve an inpatient population requiring intensive services for treatment.

“Local Contact Agency”: refers to each State’s designated community contact agencies that can provide individuals with information about community living options and available supports and services. These local contact agencies may be a single entry point agency, such as an Aging and Disability Resource Center (ADRC), an Area Agency on Aging (AAA), a Center for Independent Living (CIL), or other state designated entities.

“Long Term Care Hospital (LTCH)”: are certified as acute-care hospitals, but focus on patients who, on average, stay more than 25 days. Many of the patients in LTCHs are transferred there from an intensive or critical care unit. LTCHs specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home.

“Patient Assessment Data”: standardized, publicly available information derived from a post- acute care provider’s patient/resident assessment instrument, e.g., Minimum Data Set (MDS), Outcome and Assessment Information Set (OASIS).

GUIDANCE §483.21(c)(1)
Discharge Planning
Discharge planning is the process of creating an individualized discharge care plan, which is part of the comprehensive care plan. It involves the interdisciplinary team (as defined in §483.21(b)(2)(ii) working with the resident and resident representative, if applicable, to develop interventions to meet the resident’s discharge goals and needs to ensure a smooth and safe transition from the facility to the post-discharge setting. Discharge planning begins at admission and is based on the resident’s assessment and goals for care, desire to be discharged, and the resident’s capacity for discharge. It also includes identifying changes in the resident’s condition, which may impact the discharge plan, warranting revisions to interventions. A well-executed discharge planning process, without avoidable complications, maximizes each resident’s potential to improve, to the extent possible, based on his or her clinical condition. An inadequate discharge planning process may complicate the resident’s recovery, lead to admission to a hospital, or even result in the resident’s death.

The discharge care plan is part of the comprehensive care plan and must:

• Be developed by the interdisciplinary team and involve direct communication with theresident and if applicable, the resident representative;
• Address the resident’s goals for care and treatment preferences;
• Identify needs that must be addressed before the resident can be discharged, such asresident education, rehabilitation, and caregiver support and education;
• Be re-evaluated regularly and updated when the resident’s needs or goals change;
• Document the resident’s interest in, and any referrals made to the local contact agency;
• Identify post-discharge needs such as nursing and therapy services, medical equipmentor modifications to the home, or ADL assistanceResident Discharge to the CommunitySection Q of the Minimum Data Set (MDS) requires that individuals be periodically assessed for their interest in being transitioned to community living, unless the resident indicates otherwise. See: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQIMDS30TrainingMaterials.html.For residents who want to be discharged to the community, the nursing home must determine if appropriate and adequate supports are in place, including capacity and capability of the resident’s caregivers at home. Family members, significant others or the resident’s representative should be involved in this determination, with the resident’s permission, unless the resident is unable to participate in the discharge planning process.Each situation is unique to the resident, his/her family, and/or guardian/legally authorized representative. A referral to the Local Contact Agency (LCA) may be appropriate for many individuals, who could be transitioned to a community setting of their choice. The nursing home staff is responsible for making referrals to the LCA, if appropriate, under the process that the State has established. Nursing home staff should also make the resident and if applicable, the

 

resident representative aware that the local ombudsman is available to provide information and assist with any transitions from the nursing home.
For residents who have been in the facility for a longer time, it is still important to inquire, as appropriate, whether the resident would like to talk with LCA experts about returning to the community. New or improved community resources and supports may have become available since the resident was first admitted which may now enable the resident to return to a community setting.

If the resident is unable to communicate his or her preference or is unable to participate in discharge planning, the information should be obtained from the resident’s representative.

Discharge planning must include procedures for:

• Documentation of referrals to local contact agencies, the local ombudsman, or otherappropriate entities made for this purpose;
• Documentation of the response to referrals; and
• For residents for whom discharge to the community has been determined to not befeasible, the medical record must contain information about who made that decision and the rationale for that decision.Discharge planning must identify the discharge destination, and ensure it meets the resident’s health and safety needs, as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility must treat this situation similarly to refusal of care, and must:

• Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location;
• Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed;
• Document that despite being offered other options that could meet the resident’s needs, the resident refused those other more appropriate settings;
• Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge.As appropriate, facilities should follow their policies, or state law as related to discharges which are Against Medical Advice (AMA).Residents who will be discharged to another SNF/NF, HHA, IRF, or LTCHIf a resident will be discharged to another SNF, an IRF, LTCH, or HHA, the facility must assist the resident in choosing an appropriate post-acute care provider that will meet the resident’s needs, goals, and preferences. Assisting the resident means the facility must compile available data on other appropriate post-acute care options to present to the resident. Information the facility must gather about potential receiving providers includes, but is not limited to:

• Publicly available standardized quality information, as reflected in specific quality measures, such as the CMS Nursing Home Compare, Home Health Compare, Inpatient

Rehabilitation Facility (IRF) Compare, and Long-Term Care Hospital (LTCH) Compare

websites, and
• Resource use data, which may include, number of residents/patients who are discharged

to the community, and rates of potentially preventable hospital readmissions.

The listing of potential providers and data compiled must be relevant to the resident’s needs, and be aligned with the resident’s goals of care and treatment preferences.
Facilities must also comply with Section 1128B of the Social Security Act (the Federal Anti- Kickback statute) when making referrals to other provider types. Section 1128B “prohibits the knowing and willful offer, payment, solicitation, or receipt of any remuneration, in cash or in kind, to induce or in return for referring an individual for the furnishing or arranging of any item or service for which payment may be made under a Federal health care program,” https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity- Education/Downloads/fwa-laws-resourceguide.pdf.

In order to emphasize resident involvement, facilities are expected to present provider information to the resident and resident representative, if applicable, in an accessible and understandable format. For example, the facility should provide the aforementioned quality data on other post-acute care providers that meet the resident’s needs, goals, and preferences, and are within the resident’s desired geographic area. Facilities must then assist residents and/or resident representative as they seek to understand the data and use it to help them choose a post-acute care provider, or other setting for discharge, that is best suited to their goals, preferences, needs and circumstances. For residents who are discharged to another SNF/NF, a HHA, IRF, or LTCH the facility must provide evidence that the resident and if applicable, the resident representative was given provider information that includes standardized patient assessment data, and information on quality measures and resource use (where that data is available).

POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION
F624: For concerns related to the immediate orientation and preparation necessary for a transfer which does not require discharge planning, such as transfers to a hospital emergency room or therapeutic leave.

Summary of Investigative Procedures

Use the Community Discharge Critical Element (CE) Pathway, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the facility’s requirement to develop and implement an effective discharge planning process.

Briefly review the most recent comprehensive assessments, comprehensive care plan (specifically the discharge care plan), progress notes, and orders to identify whether the facility has identified and addressed the resident’s goals and discharge needs. This information will guide observations and interviews to be made in order to corroborate concerns identified. If there are concerns related to systematic discharge planning, this may trigger a review of the nursing home’s policies and procedures for discharge assessment and care planning.

NOTE: Always observe for visual cues of psychosocial distress and harm (see Appendix P, Guidance on Severity and Scope Levels and Psychosocial Outcome Severity Guide).

 

DEFICIENCY CATEGORIZATION
An example of Level 4, immediate jeopardy to resident health or safety, includes, but is not limited to:

• The facility failed to ensure that the post-discharge destination and continuing care provider could meet the resident’s needs prior to the discharge of a resident with a feeding tube to a residential group facility. The surveyor discovered that within 24 hours of discharge, the resident was transferred to the hospital for aspiration, was intubated for respiratory distress and diagnosed with brain death. Review of medical records showed no documentation of the resident’s tube feeding needs in the discharge plan, or whether the nursing home informed the receiving facility of the presence of the feeding tube and the need for aspiration precautions. It was also unclear whether the nursing home had determined that the receiving facility had the ability to care for a resident with a feeding tube prior to placement of the individual.

Examples of level 3, actual harm that is not immediate jeopardy include, but are not limited to:

• The facility failed to develop and/or implement a discharge care plan for a resident who had expressed a desire to return home as soon as possible once she completed rehabilitation for a fractured hip. The medical record revealed the therapist had discontinued the active treatment one week ago. The resident stated and the medical record verified that the facility had not developed plans for her care after her discharge and had not contacted any community providers to assist in her discharge. She indicated that she has not slept well due to worrying about returning to her home and paying the rent while in the facility. The resident’s home was over an hour away. She stated she was depressed over having to remain in the nursing home, and spent most of the day in her room as it was too far for her friends to visit.
• A facility failed to develop discharge plans to meet the needs and goals of each resident, resulting in significant psychosocial harm, when the facility determined it would be closing, necessitating the discharge of all residents. The facility notified residents and resident representatives it would assist with relocation. Interviews with residents and observations showed residents were agitated, fearful, and in tears over the impending move. Residents indicated they were not asked their preferences and many would be relocated far away from family. Residents also indicated they were not given opportunities to provide input into the discharge planning process, specifically regarding discharge location. Record review showed no evidence of interaction with residents or resident representatives related to discharge planning. This was cross-referenced and cited at F845, Facility Closure.An example of Level 2, no actual harm with potential for than more than minimal harm that is not immediate jeopardy, includes, but is not limited to:

• Facility failed to develop a discharge care plan that addressed all of the needs for a resident being discharged home. Specifically, the care plan did not address the resident’s need for an oxygen concentrator at home. After the resident was discharged to his home, a family member had to contact the physician to obtain the order and make arrangements for delivery of the equipment. Although there was a delay in obtaining the oxygen

concentrator, the resident did not experience harm, however this four-hour delay had a potential for compromising the residents’ ability to maintain his well-being.

Severity Level 1 does not apply for this regulatory requirement. The failure of the facility to provide appropriate discharge assessment and planning in order to meet the resident’s needs and goals at the time of discharge from the nursing home and to ensure communication of necessary information for a safe transition of care places the resident at risk for more than minimal harm.

F661
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:

(i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.

(ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative.

(iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter).

(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services.

INTENT of §483.21(c)(2)

To ensure the facility communicates necessary information to the resident, continuing care provider and other authorized persons at the time of an anticipated discharge.

DEFINITIONS §483.21(c)(2)
“Anticipated Discharge”: A discharge that is planned and not due to the resident’s death or an emergency (e.g., hospitalization for an acute condition or emergency evacuation).

“Continuing Care Provider”: The entity or person who will assume responsibility for the resident’s care after discharge. This includes licensed facilities, agencies, physicians, practitioners, and/or other licensed caregivers.

“Recapitulation of Stay”: A concise summary of the resident’s stay and course of treatment in the facility.

“Reconciliation of Medications”: A process of comparing pre-discharge medications to post- discharge medications by creating an accurate list of both prescription and over the counter

medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.

GUIDANCE §483.21(c)(2)
Overview
The discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident’s plans for care after discharge. A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another. The discharge summary may help reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident’s care.

In the case of discharge to a non-institutional setting such as the resident’s home, provision of a discharge summary, with the resident’s consent, to the resident’s community-based physicians/practitioners allows the resident to receive continuous and coordinated, person- centered care.

For residents who are being discharged from the facility to another health care facility, the discharge summary enables the receiving facility to provide appropriate and timely care. The medical record must identify the receiving facilities for which or physicians/practitioners to whom the discharge summary is provided.

Content of the Discharge Summary
Recapitulation of Resident’s Stay
Recapitulation of the resident’s stay describes the resident’s course of treatment while residing in the facility. The recapitulation includes, but is not limited to, diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results.

Final Summary of Resident Status

In addition to the recapitulation of the resident’s stay, the discharge summary must include a final summary of the resident’s status which includes the items from the resident’s most recent comprehensive assessment identified at §483.20(b)(1)(i) – (xviii) Comprehensive Assessment. This is necessary to accurately describe the current clinical status of the resident. Items required to be in the final summary of the resident’s status are:

• Identification and demographic information; • Customary routine;
• Cognitive patterns;
• Communication;

• Vision;
• Mood and Behavior patterns;
• Psychosocial well-being;
• Physical functioning and structural problems; • Continence;
• Disease diagnoses and health conditions;

• Dental and nutritional status
• Skin condition;
• Activity pursuit;
• Medications;
• Special treatments and procedures;
• Discharge planning (as evidenced by most recent discharge care plan);,
• Documentation of summary information regarding the additional assessment performedon the care areas triggered by the completion of the MDS; and
• Documentation of participation in assessment. This refers to documentation of whoparticipated in the assessment process. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care/direct access staff members on all shifts.NOTE: In addition to the above, pursuant to §483.15(c)(2)(iii), the facility (transferring nursing home) must convey the following information to the receiving provider when a resident is discharged (or transferred) from that facility:
  • Contact information of the practitioner (at the transferring nursing home) responsible for the care of the resident;
  • Resident representative information, if applicable, including contact information;
  • Advance directive information;
  • All special instructions or precautions for ongoing care, as appropriate;
  • Comprehensive care plan goals; and
  • All other necessary information, including a copy of the resident’s discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.For concerns related to the above, see guidance at F622, §483.15(c)(2)(iii).Timing of the Discharge Summary
    The discharge summary contains necessary medical information that the facility must furnish at the time the resident leaves the facility, to the receiving provider assuming responsibility for the resident’s care after discharge. The discharge summary may be furnished in either hard copy or electronic format, if the provider assuming responsibility for the resident’s care has the capacity to receive and use the discharge summary in electronic format. Delays in preparing and forwarding the discharge summary hinder the coordination required to provide optimal care to the resident. The medical record must contain the discharge summary information and identify the recipient of the summary.NOTE: In situations where there is no continuing care provider (e.g., resident has no primary care physician in the community), the facility is expected to document in the medical record efforts to assist the resident in locating a continuing care provider.Reconciliation of Medications Prior to DischargeA resident’s discharge medications may differ from what the resident was receiving while residing in the facility. Facility staff must compare the medications listed in the discharge

summary to medications the resident was taking while residing in the nursing home. Any discrepancies or differences found during the reconciliation must be assessed and resolved, and the resolution documented in the discharge summary, along with a rationale for any changes. For example, a resident who was receiving rehabilitative services may have required antibiotic therapy postoperatively but does not need to continue the antibiotic at home. The discontinuation of the medication should be documented in the discharge summary.

Discharge instructions and accompanying prescriptions provided to the resident and if applicable, the resident representative must accurately reflect the reconciled medication list in the discharge summary.

Post-Discharge Plan of Care

The post-discharge plan of care details the arrangements that facility staff have made to address the resident’s needs after discharge, and includes instructions given to the resident and his or her representative, if applicable. The post-discharge plan of care must be developed with the participation of the Interdisciplinary team and the resident and, with the resident’s consent, the resident’s representative. At the resident’s request, a representative of the local contact agency may also be included in the development of the post-discharge plan of care. The post-discharge plan of care should show what arrangements have been made regarding:

• Where the resident will live after leaving the facility;
• Follow-up care the resident will receive from other providers, and that provider’s contact

information;
• Needed medical and non-medical services (including medical equipment); • Community care and support services, if needed; and
• When and how to contact the continuing care provider.

Instructions to residents discharged to home

For residents discharged to their home, the medical record should contain documentation that written discharge instructions were given to the resident and if applicable, the resident representative. These instructions must be discussed with the resident and resident representative and conveyed in a language and manner they will understand.

KEY ELEMENTS OF NONCOMPLIANCE

To cite deficient practice at F661, the surveyor’s investigation will generally show that the facility failed to do one or more of the following:

• Prepare a discharge summary that includes all of the following:
o A recapitulation (containing all required components) of the resident’s stay; o A final summary of the resident’s status (that includes the items listed in

§483.20(b)(1));
o A reconciliation of all pre and post discharge medications;
o A discharge plan of care (containing all required components); or

• Reconcile the resident’s pre-discharge medications with his/her post-discharge medications; or
• Convey the discharge summary to the continuing care provider or receiving facility at the time of discharge

DEFICIENCY CATEGORIZATION
An example of Level 4, immediate jeopardy to resident health or safety, includes, but is not limited to:

• A resident experienced a stroke during the SNF stay and was started on Coumadin. The resident was then discharged to another facility but the discharge summary did not include the new orders for Coumadin and PT/INR monitoring. The receiving facility did not start the resident on Coumadin and the resident experienced another stroke.

An example of level 3, actual harm that is not immediate jeopardy includes, but is not limited to:

• Review of a discharge summary for a discharged resident showed that the discharge summary did not contain necessary information about the resident’s wound care care needs and arrangements for wound care after discharge. Investigation showed that the resident did not receive appropriate wound care at home because details of wound care received in the facility were not conveyed in the discharge summary. The facility’s failure to provide instructions for the care of the wound in the discharge summary information caused the resident’s wound to worsen at home resulting in readmission to a hospital.

An example of Level 2, no actual harm with potential for than more than minimal harm that is not immediate jeopardy, includes, but is not limited to:

• A resident was discharged to another facility closer to her family. The transferring facility did not send a complete discharge summary to the receiving facility until one week after the resident was admitted to the new facility. The receiving facility had to take additional time and use multiple sources to verify medications and other medical orders while waiting for a complete discharge summary. This placed the resident at risk for more than minimal harm due to the potential for inaccuracies in medication and other orders while waiting for a complete discharge summary.

An example of Level 1, no actual harm with potential for no more than a minor negative impact on the resident, includes, but is not limited to:

• The failure of the facility to provide in its recapitulation of the resident’s stay, the most recent laboratory results (which were normal). This resulted in no negative impact to the resident.

The information presented is informative and does not constitute direct legal or regulatory advice

September 2024\Skilled Nursing Support\maria.messina@skillednursingsupport.com

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