CMS SOM App. W, Tag C-1620

planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the

CAH is not required to use the resident assessment instrument (RAI) specified by

the State that is required under §483.20(b), or to comply with the requirements for

frequency, scope, and number of assessments prescribed in §413.343(b) of this

chapter).

• §483.20(b) Comprehensive assessments—

(1) Resident assessment instrument. A facility must make a

comprehensive assessment of a resident's needs, strengths, goals, life

history and preferences, using the resident assessment instrument

(RAI) specified by CMS. The assessment must include at least the

following:

(i) Identification and demographic information.

(ii) Customary routine.

(iii) Cognitive patterns.

(iv) Communication.

(v) Vision.

(vi) Mood and behavior patterns.

(vii) Psychosocial well-being.

(viii) Physical functioning and structural problems.

(ix) Continence.

(x) Disease diagnoses and health conditions.

(xi) Dental and nutritional status.

(xii) Skin condition.

(xiii) Activity pursuit.

(xiv) Medications.

(xv) Special treatments and procedures.

(xvi) Discharge planning.

(xvii) Documentation of summary information regarding the

additional assessment performed on the care areas triggered by

the completion of the Minimum Data Set (MDS).

(xviii) Documentation of participation in assessment. The assessment

process must include direct observation and communication

with the resident, as well as communication with licensed and

nonlicensed direct care staff members on all shifts.

(2) When required. Subject to the timeframes prescribed in §413.343(b)

of this chapter, a facility must conduct a comprehensive assessment of

a resident in accordance with the timeframes specified in paragraphs

(b)(2) (i) through (iii) of this section. The timeframes prescribed in

§413.343(b) of this chapter do not apply to CAHs.

(i) Within 14 calendar days after admission, excluding readmissions in

which there is no significant change in the resident's physical or

mental condition. (For purposes of this section, “readmission”

means a return to the facility following a temporary absence for

hospitalization or for therapeutic leave.)

(ii) Within 14 calendar days after the facility determines, or should

have determined, that there has been a significant change in the

resident's physical or mental condition. (For purposes of this

section, a “significant change” means a major decline or

improvement in the resident's status that will not normally resolve

itself without further intervention by staff or by implementing

standard disease-related clinical interventions, that has an impact

on more than one area of the resident's health status, and requires

interdisciplinary review or revision of the care plan, or both.)

(iii) Not less often than once every 12 months.

• §483.21(b) Comprehensive care plans.

(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident

rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes

measurable objectives and timeframes to meet a resident's medical,

nursing, and mental and psychosocial needs that are identified in the

comprehensive assessment. The comprehensive care plan must

describe the following:

(i) 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 §483.24, §483.25, or §483.40; and

(ii) Any services that would otherwise be required under §483.24,

§483.25, or §483.40 but are not provided due to the resident's

exercise of rights under §483.10, including the right to refuse

treatment under §483.10(c)(6).

(1) Any specialized services or specialized rehabilitative services the

nursing facility will provide as a result of PASARR

recommendations. If a facility disagrees with the findings of the

PASARR, it must indicate its rationale in the resident's medical

record.

(2) In consultation with the resident and the resident's

representative(s)—

(A) The resident's goals for admission and desired outcomes.

(B) The resident's preference and potential for future discharge.

Facilities must document whether the resident's desire to

return to the community was assessed and any referrals to

local contact agencies and/or other appropriate entities, for

this purpose.

(C) Discharge plans in the comprehensive care plan, as

appropriate, in accordance with the requirements set forth in

paragraph (c) of this section.

(2) A comprehensive care plan must be—

(i) Developed within 7 days after completion of the comprehensive

assessment.

(ii) Prepared by an interdisciplinary team, that includes but is not

limited to-

(A) The attending physician.

(B) A registered nurse with responsibility for the resident.

(C) A nurse aide with responsibility for the resident.

(D) A member of food and nutrition services staff.

(E) To the extent practicable, the participation of the resident and

the resident's representative(s). An explanation must be

included in a resident's medical record if the participation of

the resident and their resident representative is determined not

practicable for the development of the resident's care plan.

(F) Other appropriate staff or professionals in disciplines as

determined by the resident's needs or as requested by the

resident.

(iii) Reviewed and revised by the interdisciplinary team after each

assessment, including both the comprehensive and quarterly review

assessments.

(3) The services provided or arranged by the facility, as outlined by the

comprehensive care plan, must—

(i) Meet professional standards of quality.

(ii) Be provided by qualified persons in accordance with each

resident's written plan of care.

(iii) Be culturally-competent and trauma-informed.

• §483.21(c)(2) Discharge summary. When the facility anticipates discharge a

resident must have a discharge summary that includes, but is not limited to,

the following:

(i) A recapitulation of the resident's stay that includes, but is not

limited to, diagnoses, course of illness/treatment or therapy, and

pertinent lab, radiology, and consultation results.

(ii) A final summary of the resident's status to include items in

paragraph (b)(1) of §483.20, at the time of the discharge that is

available for release to authorized persons and agencies, with the

consent of the resident or resident's representative.

(iii) Reconciliation of all pre-discharge medications with the resident's

post-discharge medications (both prescribed and over-the-counter).

(iv) A post-discharge plan of care that is developed with the

participation of the resident and, with the resident's consent, the

resident representative(s), which will assist the resident to adjust to

his or her new living environment. The post-discharge plan of care

must indicate where the individual plans to reside, any

arrangements that have been made for the resident's follow up care

and any post-discharge medical and non-medical services.

Interpretive Guidelines §485.645(d)(5)

Refer to Appendix PP of the State Operations Manual (SOM) for interpretive guidelines.

Survey Procedures §485.645(d)(5)

Refer to Appendix PP of the State Operations Manual (SOM) for survey procedures.

*NOTE: The CAH is not required to use the resident assessment instrument (RAI)

specified by the State that is required under §483.20(b), or to comply with the

requirements for frequency, scope, and number of assessments prescribed in §413.343(b)

of this chapter). Also, note that CAHs are not required to complete the PASARR.

However, if a patient had a PASARR completed by a facility that was required to do

so prior to admission into a CAH swing bed, the recommendations from the

PASARR should be included in the CAHs comprehensive treatment plan for the

patient.