Baseline care plans have been required since late November 2017, but nurse assessment coordinators (NACs) and other interdisciplinary team (IDT) members are still navigating through a lot of misinformation to learn the rules of the road for F655 (Baseline Care Plans) as detailed in Appendix PP of the State Operations Manual.
Here are seven common myths that need to be vanquished:
Myth: NACs should be able to complete all baseline care plans on their own
“The baseline care plan must be developed and implemented within 48 hours of admission, regardless of the day or time of admission,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “In other words, Saturday and Sunday count in the 48 hours. For most communities, this means that the baseline care plan cannot be the sole responsibility of the NAC, who often doesn’t work weekends.”
In fact, care planning and communication with residents about their care should always have been occurring on an as-needed basis 24 hours a day, seven days a week, points out Hillier. “So it should always have been an IDT function, not solely the responsibility of the NAC. Since Nov. 28, 2017, communities are learning effective ways to share the care planning and communication responsibilities in order to be responsive to the new timeframe requirements, as well as to changes in the resident condition that can occur at any time of the day or day of the week.”
Myth: Providers must deliver the actual baseline care plan to the resident/representative
“The requirement is to provide a summary of the baseline care plan in language the resident and/or their representative can understand,” says Hillier. “For most communities, this is a different document than the actual baseline care plan that is in place for the staff to follow.”
Myth: The resident needs to sign the baseline care plan
The baseline care plan does not need to be signed by the resident, states Melanie Tribe-Scott, RN, RAC-MT, QCP, director of clinical reimbursement for Health Concepts in Providence, RI. “Many NACs appear to be confusing the baseline care plan requirements under F655 with the interpretive guidance for F553 (Right to Participate in Planning Care).”
F553 says that the resident has the right to see the care plan, including the right to sign (should they choose to) after significant changes are made to the care plan, she notes. “The intent of that regulation is to ensure that facility staff include the resident or their representative in all the aspects of person-centered care planning. This is in reference to the comprehensive care plan.”
F655 requires that facilities provide residents with a written baseline care plan summary, and nothing in the interpretive guidance indicates that the resident must sign the summary, says Tribe-Scott. Instead, the regulation at F655 tells providers that “… the medical record must contain evidence that the summary was given to the resident and resident representative, if applicable.”
“So you need to make sure the medical record includes documentation that you provided the summary, but that proof doesn’t necessarily have to be the resident’s signature,” explains Tribe-Scott.
Myth: The baseline care plan summary needs to be delivered to the resident/representative within 48 hours
“The baseline care plan has to be developed and implemented within 48 hours of admission, but the summary doesn’t have to be delivered within 48 hours,” points out Tribe-Scott. “The facility has to provide the resident or representative with the written summary of the baseline care plan by the completion of the initial comprehensive care plan. Providers can take up to 21 days after admission to complete the comprehensive care plan. As long as you give the summary to the resident/representative by the time you have completed that comprehensive care plan, you are meeting the regulation.”
However, waiting until the comprehensive care plan is completed to provide the written baseline care plan summary may not be the best approach, suggests Tribe-Scott “Forty-eight hours may be too early, but 21 days could be too late. It would really be more beneficial for the resident to provide the baseline care plan summary prior to the completion of the comprehensive care plan. Investing the time to talk to the resident/representative and making sure they agree with the plan you’ve outlined in the baseline care plan can provide your IDT with information that is pertinent to the completion of the comprehensive care plan. For example, if you find out during the discussion of the baseline care plan that the resident doesn’t agree with staying in your facility long-term, the resident’s choice could impact the development of the comprehensive care plan, so you need to be aware of it before the comprehensive care plan is finished.”
Note: Providers also may need to provide an updated baseline care plan summary. The following excerpt from F655 explains:
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.
Myth: Long-stay residents who discharge-return anticipated need a baseline care plan upon re-entry
Consider this scenario: A resident who is a long-term care patient goes out to the hospital as discharge-return anticipated. They already have a comprehensive care plan in place because of their long-stay status.
“When this resident who discharged-return anticipated returns to the same facility after a hospital stay, some providers put in place a baseline care plan,” points out Tribe-Scott. “However, a baseline care plan isn’t needed because you’ve already developed a comprehensive care plan for that patient. A baseline care plan has to be developed within 48 hours of admission, not within 48 hours of re-entry.”
Instead of creating a baseline care plan, the facility is supposed to review and revise the comprehensive care plan upon the resident’s return if the resident was discharged with a return anticipated and returns within 30 days, she explains. “At that time, the IDT also should be determining if the resident would meet the requirements for a significant change assessment.”
Myth: Risks aren’t an important component of the baseline care plan
The F655 guidance states that, at a minimum, the baseline care plan must address: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; and the PASARR recommendation, if applicable. “Many providers get caught up in meeting these requirements and forget the risks, but the whole purpose of the baseline care plan is to increase the resident’s safety and safeguard them against adverse events that are most likely to happen right after admission,” says Tribe-Scott.
So the baseline care plan also should address risks that may cause the resident to return to the hospital, she adds. “For example, it should address issues such as fall risk, skin integrity, elopement, and active infections, as well as any behaviors that might put that resident at risk. The dietary orders and the other listed requirements are important, but you also need to include the risks.” Note: For additional details, review the F655 guidance on the baseline care plan content requirements.
Myth: The baseline care plan has to have the same level of detail as the comprehensive care plan
“Chapter 4, ‘Care Area Assessment Process,’ of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual has always required an ‘interim’ care plan be in place from the time of admission to give basic instructions to the staff as to how to deliver care until completion of the comprehensive care plan,” notes Hillier.
“This ‘new’ requirement for a baseline care plan simply adds more specificity to the process. The baseline care plan will include the overall goal of the resident, services that have been determined within the first 48 hours to be needed, and interventions deemed to be appropriate as a result of various admission assessments by the IDT,” says Hillier. While the baseline care plan needs to include the required components outlined in the interpretive guidance in F655, “there is no expectation that the baseline care plan will be as detailed as the comprehensive care plan,” she points out.
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