CMS SOM App. PP, Tag F655

§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 a

resident 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 (excepting

paragraph (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 acting

on behalf of the facility.

(iv) Any updated information based on the details of the comprehensive care plan, as

necessary.

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; and

o Any updated information based on details of the admission comprehensive

assessment.