Baseline Care Plans: How NACs Can Prepare

Posted By: Caralyn Davis, Staff Writer
Post Date: 07/26/2017

Effective Nov. 28, 2017, nursing homes that participate in the Medicare and/or Medicaid programs have to complete and implement a baseline care plan within 48 hours of a resident’s admission, as well as provide a baseline care plan summary to the resident (and representative if necessary) by the completion of the comprehensive care plan. On June 30, the Centers for Medicare & Medicaid Services released an advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual, offering some important details about the baseline care plan implementation requirements in F-tag 655. (See excerpt at the end of this article.)

“The baseline care plan dovetails nicely with so many CMS initiatives that demand rapid, detailed assessment with immediate care planning to move the resident through the system as fast as possible to shorten a Part A stay,” says Judy Wilhide Brandt, RN, BA, QCP, CPC, RAC-MT, DNS-CT, principal of Wilhide Consulting in Virginia Beach, VA. “If the resident is coming in for long-term care, this requirement will force providers to quickly assess and start helping the resident meet their goals.”

The baseline care plan shouldn’t be a huge change in direction for providers that have a strong interim care planning process in place, suggests Brandt. “Facilities have been doing an interim care plan to cover the resident’s immediate needs—it just hasn’t had the required detail before. But really, the requirements for the baseline care plan are pretty much what we’ve had in the interim care plan for many years.”

However, the reality is that the baseline care plan likely will be a big deal for many facilities that haven’t focused a lot of attention on the interim care plan, says Beckie Dow, RN, RAC-MT, a nurse consultant in Bell, FL. “It will require additional work when everyone is so busy. Providers should plan the steps they need to take to ensure they are meeting this requirement by Nov. 28.”

Here are some steps that nurse assessment coordinators (NACs) can take to jumpstart their role as project manager for the baseline care plan:


* Start preparing now

“It would be a good idea to start practicing this before it becomes a requirement,” says Dow. “Providers need to look at how they are going to collect that data and what each interdisciplinary (IDT) member’s role will be to meet this requirement to the best advantage of the patient.”


* Use the AADNS Baseline Care Plan Tool as a guide

AANAC's sister organization, AADNS, has developed a Baseline Care Plan Tool that includes a suggested workflow for rolling out the baseline care planning process, as well as two suggested checklists: one covering potential roles and responsibilities, and the other covering the development of the baseline care plan itself. “The workflow diagram can help NACs be the lead in walking the IDT through the changes that need to happen,” suggests Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.


* Stress interdisciplinary participation

Over the years, many providers have assigned care planning as the sole responsibility of the NACs, says Hillier. “With the 48-hour deadline for baseline care plans, relying on the MDS coordinator to do that is not going to work. So NACs need to help educate the facility that care planning is an interdisciplinary process that needs to start on admission.”

NACs may not always be in the best position to do baseline care plans, adds Hillier. “For example, if a resident is admitted on a Friday night and the NAC doesn’t work weekends, relying on the NAC alone to do the baseline care plan is not going to work.”

In addition, providers need to consider the quality of the baseline care plan, advises Dow. “If facilities look for the MDS coordinator to do 100 percent of this requirement on all patients, that NAC may not have the time or the interdisciplinary insight to create a robust-enough care plan to guide the patient’s care in the way that the regulation is intending.”

One option to consider is for the baseline care plan to be “set up by the admission nurses and then fleshed out by other required IDT members in the 48-hour period,” says Brandt. “However, if the 48 hours are over a weekend, then nursing is the most likely choice to do it. In addition, the new interpretive guidelines make it clear that this care plan must be updated and shared with the resident or representative up until the comprehensive person-centered care plan is done.”


* Examine your IDT’s baseline admission assessments

“Facilities have always had baseline admission assessments that are completed by various disciplines,” says Hillier. “However, over time some providers forgot that the purpose of those interdisciplinary baseline assessments is to drive care planning from the moment of admission. Often, IDT members put away those interdisciplinary admission assessments in a file (e.g., for the MDS coordinator to see when she comes to work on Monday or to demonstrate compliance to a surveyor).”

So NACs should work with the IDT to evaluate the efficacy of every interdisciplinary assessment that is already being completed on admission to ensure team members are obtaining the necessary information to develop a compliant baseline care plan, suggests Hillier.

“This is going to be a great opportunity to shore up the initial nursing assessments, social services, dietary, and all other IDT initial assessments,” agrees Brandt. “Providers with strong systems for initial assessment and identification of needs/wants/strengths will be the real winners.”


* Educate and mentor the IDT about care planning

 “With the baseline care plans, NACs should educate and mentor the various IDT members who might need to do their own care planning. Many of them haven’t done care planning in a long time, so the NAC has a key role in educating them on the best ways to do that.”

MDS coordinators also can help re-educate IDT members about how to use baseline admission assessments to put in place interventions for that baseline care plan, says Hillier. “For example, when the floor nurse does the nursing assessment on admission, that might trigger an immediate intervention because the resident is at high risk for pressure ulcers. Or the dietary admission assessment will put dietary interventions and care plans in place right away.”

In addition, it’s important for NACs to educate IDT members about the need to individualize any template care plans that they may use, says Dow. “The goal is to develop a baseline care plan that shows critical thinking about each particular patient: ‘I’ve gathered this data about this patient’s needs. Now what do I need to do with this data that I have already collected?’ That’s really the piece that sometimes is missing in IDT members who haven’t had education about care planning or an opportunity to develop critical thinking skills as part of their work repertoire.”

NACs also can play a role in ensuring every discipline knows when their initial assessment is due for working on the baseline care plan—and when that 48-hour window closes for the care plan itself, says Dow. “Getting that system up and running could be a challenge.”


* Re-think traditional care conference timing

Providers that already have a strong interim care plan process typically have “an initial care planning meeting in the first two or three days as a matter of routine care,” notes Brandt. Those facilities may have to slightly adjust their timetable to meet the 48-hour deadline for the baseline care plan.

However, many providers have followed the same system for years when a resident is admitted: The IDT takes the first two weeks following admission to do the Admission MDS and decide what will be in the care plan. Then during the third week post-admission at the end of the MDS completion process, the facility holds a care conference to share the care plan with the resident and family.

“The requirement for a baseline care plan offers NACs a great opportunity to re-evaluate this process,” suggests Hillier. “Starting with a family and resident ‘care conference’ at the beginning of the stay will help the IDT ask the questions that will incorporate the resident’s initial goals for care into the baseline care plan: ‘What is the primary reason you are here? What is your main goal? Is your goal to return home? Is your goal long-term placement?’”

“Although sharing the baseline care plan summary is not required until the comprehensive care plan is done, these early meetings are a fantastic way to get off on the right foot,” adds Brandt.

When the comprehensive Admission MDS and the Care Area Assessments (CAAs) are actually completed, “the IDT could have a follow-up care conference with the family and the resident to give them updates and review changes from the baseline care plan,” says Hillier. “But the bulk of that conversation could happen at the beginning of the stay.”

Adding in an admission care conference could result in the IDT providing better care to residents, notes Hillier. “With brand-new admissions, particularly Medicare residents who are admitted for skilled therapy services, nursing staff often don’t know early in the stay what the clinical drivers are for the admission, or what the plan is. The requirements for the baseline care plan may help providers turn things around so that nurses and the rest of the IDT have a better understanding of the resident’s needs and goals at the very beginning of the stay so they can provide more individualized care.”

The best practice would be to have this initial care conference within the first 24 hours of admission, advises Dow. “And honestly, 24 hours is even a bit too long. One way to do it is to have a formalized process similar to angel rounds where a management member of each discipline quickly meets with the patient, oftentimes at their bedside, to see what the patient’s goals are for their stay, as well as to learn about any cultural or religious preferences that may impact how care is delivered. Providers need to have that initial contact with the patient to identify opportunities to personalize this care plan to them.”


* Take a look at your clinical software

“Facilities need to re-evaluate their software. Obviously many of the needed interdisciplinary assessments are done or should be done electronically, so providers need to evaluate whether their software is appropriate,” says Hillier.

For example, one question to ask software vendors is “how/when they plan to provide a template for the baseline care plan that the IDT can individualize for each resident,” suggests Brandt. “However, the interpretive guidelines make it clear that a copy of the baseline care plan can be given to the resident instead of a summary. Most providers don’t have the medication list attached, but it may be easier to add the med list in plain language to the baseline care plan instead of doing a separate summary.”


* Think about discharge planning

“Talking to residents and their families earlier in the stay should put a heightened focus on discharge planning,” says Dow. “Some family members are very passionate but not realistic about taking their family members home. So when talking to residents and their families about the resident’s goals for the stay, the IDT will need to work with families more closely to help them come to a realistic perception about the potential for discharge.”


* Remember the care plan is never done

“The IDT should be working on the care plan for as long as the resident is in the facility because it is designed to be a fluid document that is updated as the patient’s needs and wants change,” says Dow. “So it would be a mistake to focus on just the 48-hour deadline for the baseline care plan and the deadline for a comprehensive care plan seven days after the initial comprehensive assessment. Care plans should be good working tools that extend past these regulatory deadlines.”



Baseline care plans: What CMS says in Appendix PP




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




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:

· The resident’s initial goals for care;

· The instructions needed to provide effective and person-centered care that meets professional standards of quality care;

· The resident’s immediate health and safety needs;

· Physician and dietary orders;

· PASARR recommendations, if applicable; and

· 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)?


Source: Excerpted from F655 in the advance copy of Appendix PP of the State Operations Manual. See F655 for guidance specific to the baseline care plan summary.



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