Baseline Care Plans and the 48-Hour Rule: CMS Gives AANAC Some Insights

Posted By: Caralyn Davis, Staff Writer
Post Date: 01/31/2018

Even industry experts are often confused by the rules for baseline care plans laid out in F655 in Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual, particularly what exactly does—and doesn’t—have to be done within that initial 48-hour window post-admission. So AANAC asked the Centers for Medicare & Medicaid Services (CMS) to confirm or deny three suppositions. The responses provided by a CMS official answer quite a few questions, including how MDS item V0200C2 (Date of Care Planning) fits into the picture and the requirements for providing an updated baseline care plan. Here are their insights.

 

Supposition 1: The baseline care plan must be developed and implemented within 48 hours of a resident's admission, and there are no exceptions to this requirement made for holidays, weekends, night admissions, etc. This baseline care plan must include but is not limited to the minimum health information cited in F655: (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. 

 

CMS response: You are correct. The facility is required to develop and implement a baseline care for each resident within 48 hours of admission to the facility. There are no exceptions to this requirement for holidays, weekends, or night admissions, and the baseline care plan is required to address, at a minimum, the following: Initial goals based on admission orders, Physician orders, Dietary orders, Therapy services, Social services, and PASARR recommendations if applicable.

 

The guidance at F655 says that, at a minimum, the baseline care plan must include “the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care” and “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.”

 

Supposition 2: The written summary of the baseline care plan does not have to be provided to the resident/representative within 48 hours of a resident's admission. Rather, it must be provided by completion of the comprehensive care plan. Per chapter 2 of the RAI Manual, the initial comprehensive care plan must be completed by the CAA Completion Date plus seven calendar days. Therefore, the written summary of the baseline care plan must be provided by the date in MDS item V0200C2 (Date of Care Planning Decision). This summary must include: "Initial goals for the resident; A list of current medications and dietary instructions, and Services and treatments to be administered by the facility and personnel acting on behalf of the facility." 

 

CMS response: You are correct. There is no requirement to provide the resident and/or the resident’s representative with a written summary of the baseline care plan within 48 hours of admission. The State Operations Manual, at F655, states: “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.”

 

To clarify, the baseline care plan summary must be provided to the resident and/or resident representative, if applicable, by the completion of the comprehensive care plan and is not dependent upon MDS item V0200B2 (CAA Process Completion Date). According to 42 CFR “§483.21(b)(2) A comprehensive care plan must be—(i) Developed within 7 days after completion of the comprehensive assessment.” The completion date of the comprehensive assessment is MDS item V0200B2 (CAA Process Completion Date); therefore, the comprehensive care plan must be developed within 7 days of the date in V0200B2.

 

MDS Item V0200C2 (Date of Care Planning) is the date the comprehensive care plan is completed and also the date the baseline care plan summary must be provided to the resident and/or resident representative, if applicable. For example, if the comprehensive care plan is completed within 2 days of V0200B2, then the baseline care plan summary must be provided to the resident and/or resident representative by the completion of the comprehensive care plan (which is within 2 days of V0200B2 and the same date as V0200C2).

 

You are correct that, at a minimum, the baseline care plan summary must include “the initial goals for the resident; a list of current medications and dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility.”

 

Supposition 3: Per Appendix PP, if “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.” So the facility should either (1) include updated information from the comprehensive assessment and care plan in the sole written summary of the baseline care plan that it provides to the resident/representative by the date in MDS item V0200C2 (Date of Care Planning Decision), or (2) provide an updated written summary to the resident/representative by the date in MDS item V0200C2 (Date of Care Planning Decision) if it previously provided a written summary that did not contain changes identified in the comprehensive assessment and comprehensive care plan. 

 

CMS response: You are correct. If the facility provides the resident and/or representative with a summary of the baseline care plan prior to the completion of the comprehensive care plan, the facility must provide the resident and/or resident representative with an updated summary with any changes in the resident’s goals, or physical, mental, or psychosocial functioning identified when conducting the comprehensive assessment and/or developing the comprehensive care plan, by completion of the comprehensive care plan (V0200C2).

 

The guidance at F655 states: “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.” If the written summary is not provided until the completion of the comprehensive care plan, the summary must include the required baseline care plan summary components (initial resident goals, list of current medications and dietary instructions, services and treatments to be administered) and any changes in the resident’s goals, or physical, mental or psychosocial functioning as a result of the comprehensive assessment and comprehensive care plan development.



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