Current through Reg. 50, No. 13; March 28, 2025
(a) Baseline care plans.
(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:
(A) be developed within 48 hours of a
resident's admission;
(B) include
the minimum healthcare information necessary to properly care for a resident,
including:
(i) initial goals based on
admission orders;
(vi) PASRR recommendation, if
applicable.
(2) The facility may develop a comprehensive
care plan in place of the baseline care plan if the comprehensive care plan:
(A) is developed within 48 hours of the
resident's admission; and
(B) meets
the requirements set forth in subsections (b) - (g) of this section, except
subsection (c)(1) of this section.
(3) The facility must provide the resident
and the resident representative a summary of the baseline care plan that
includes:
(A) the initial goals of the
resident;
(B) a summary of the
resident's medications and dietary instructions;
(C) any services and treatments to be
administered by the facility and personnel acting on behalf of the facility;
and
(D) any updated information
based on the details of the comprehensive care plan, as necessary.
(b) A facility must
develop a comprehensive care plan for each resident, consistent with the
resident's rights, that includes measurable short-term and long-term objectives
and timeframes to meet a resident's medical, nursing, mental, and psychosocial
needs that are identified in the comprehensive assessment. If a child is
admitted to the facility, the comprehensive care plan must be based on the
child's individual needs. The comprehensive care plan must describe the
following:
(1) 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 §
554.701 of this chapter (relating
to Quality of Life) and §
554.901 of this chapter (relating
to Quality of Care);
(2) any
services that would otherwise be required under §
554.701 of this chapter and §
554.901 of this chapter but are
not provided due to the resident's exercise of rights, including the right to
refuse treatment under §
554.403(i) of
this chapter (relating to Notice of Rights and Services);
(3) any nursing facility specialized services
or nursing facility PASRR support activities the nursing facility will provide
as a result of PASRR recommendations, in accordance with Subchapter BB of this
chapter (relating to Nursing Facility Responsibilities Related To Preadmission
Screening And Resident Review (PASRR)); and
(4) in consultation with the resident and
resident representative:
(A) the resident's
goals for admission and desired outcomes;
(B) the resident's preference and potential
for future discharge, whether the resident's desire to return to the community
was assessed, and any referrals to local contact agencies or other appropriate
entities; and
(C) discharge plans
in the comprehensive care plan as appropriate, in accordance with §
554.803 of this subchapter
(relating to Discharge Summary (Discharge Plan of Care)).
(c) The comprehensive care plan
must be:
(1) developed within seven days after
completion of the comprehensive assessment;
(2) prepared by an interdisciplinary team
that includes:
(A) the attending
physician;
(B) a registered nurse
with responsibility for the resident;
(C) a nurse aide with responsibility for the
resident;
(D) the qualified
dietitian or director of food and nutrition services;
(E) other appropriate staff in disciplines as
determined by the resident's needs or as requested by the resident;
and
(F) to the extent practicable,
the participation of the resident and the resident representative;
(3) periodically reviewed and
revised by a team of qualified persons after each assessment, including both
the comprehensive and quarterly review assessments; and
(4) for a resident under 22 years of age,
annually reviewed at a comprehensive care plan meeting between the facility and
the resident's LAR as defined in §
554.805(a)(5) of
this subchapter (relating to Permanency Planning for a Resident Under 22 Years
of Age), which includes a review of:
(A) the
LAR's contact information as required by §
554.805(b)(4)(F)
of this subchapter;
(B) the
resident's comprehensive assessment;
(C) the resident's educational status;
and
(D) the resident's permanency
plan.
(d)
Regarding subsection (c)(2)(F) of this section, an explanation must be included
in a resident's clinical record if the participation of the resident and the
resident representative is determined not practicable for the development of
the resident's comprehensive care plan.
(e) A comprehensive care plan must include:
(1) for a resident under 18 years of age, the
activities, supports, and services that, when provided or facilitated by the
facility, will enable the resident to live with a family; or
(2) for a resident 18-22 years of age, the
activities, supports, and services that, when provided or facilitated by the
facility, will result in the resident having a consistent and nurturing
environment in the least restrictive setting, as defined by the resident and
LAR as defined in §
554.805(a)(5) of
this subchapter.
(f) A
comprehensive care plan may include a palliative plan of care. This plan may be
developed only at the request of the resident, surrogate decision maker or
legal representative for residents with terminal conditions, end stage diseases
or other conditions for which curative medical interventions are not
appropriate. The plan of care must have goals that focus on maintaining a safe,
comfortable and supportive environment in providing care to a resident at the
end of life.
(g) For a resident
under 22 years of age, the facility must provide written notice to the LAR, as
defined in §
554.805(a)(5) of
this subchapter, of a meeting to conduct an annual review of the resident's
comprehensive care plan no later than 21 days before the meeting date and
request a response from the LAR.
(h) The services provided or arranged by the
facility must:
(1) meet professional
standards of quality;
(2) be
provided by qualified persons in accordance with each resident's written
comprehensive care plan; and
(3)
effective November 28, 2019, be culturally-competent and
trauma-informed.
(i) The
comprehensive care plan must be made available to all direct care
staff.
