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A Guide to Developing Resident Baseline Care Plans

March 01, 2018
Documentation, Billing, & Coding By Maureen Kelly, Senior Consultant

The intent of F655 Baseline Care Plans is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that may occur 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. 

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The real issue is that nurses seem to have forgotten that care planning is the foundation of the nursing process. The Minimum Data Set (MDS), the specific standardized tools and mandated cyclical process which is coordinated by a registered nurse (RN), and conducted by a multidisciplinary team, is meant to support care planning, not to impersonate the care plan. Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is  fluid and ongoing. The lack of ongoing clinical assessment and identification of changes in conditions, to meet the resident’s needs between required RAI assessments, must be addressed in the resident’s care plan. The residents’ preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Developing Resident Baseline Care Plans

Per regulations, the facility must develop a baseline care plan within the first 48 hours of admission; providing instructions for the provision of effective and person-centered care. 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. The care plan is unique and focuses on the resident as the center of control and supports each resident in making his or her own choices. The interdisciplinary team should make every effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident regarding daily routines and preferred activities, and understanding the resident’s life before coming to reside in the nursing home. Check-off and cookie-cutter style baseline care plans do not meet the intent of the regulation. 

LW Consulting, Inc., supports the following best practices. 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 and include, at a minimum, the following:

  • Initial goals based on admission orders.
  • Physician orders.
  • Dietary orders.
  • Therapy services.
  • Social services.
  • PASARR recommendation, if applicable.

We recommend addressing residents’ preference for future discharge, early to ensure that each resident is given every opportunity to attain his/her highest quality of life.

LW Consulting, Inc. recognizes that the baseline care plan must reflect the resident’s stated goals and objectives and include interventions that address current needs versus a checklist baseline care plan.  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 dictates 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. The care plan is a living, breathing document that drives the type of care and services the resident needs at any moment in time.

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:

  • Initial goals for the resident
  • A list of current medications and dietary instructions
  • 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 as the summary, if it meets all 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. 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.

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 or 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 its development and be informed in advance of changes to the care plan, see the care plan, and sign the care plan after significant changes.

Baseline Care Plan Components

LW Consulting, Inc. recommends developing a Baseline Care Plan within 48 hours of admission.  The care plan should have a problem statement, objectives and interventions. 

As previously mentioned, the Baseline Care Plan should include, at a minimum:

  • Initial goals based on admission orders.
  • Physician orders.
  • Dietary orders.
  • Therapy services.
  • Social services.
  • PASARR recommendation, if applicable.

We recommend addressing residents’ preference for future discharge, as early to ensure that each resident is given every opportunity to attain his/her highest quality of life.

Baseline Care Plan Process

Assessment
The RN collects and analyzes data about the resident, the first step in delivering nursing care. Assessment includes physiological, psychological, sociocultural, spiritual, economic, and life-style factors. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response; an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at therapy staff, fear or request for more pain medication.

Diagnosis
The nursing diagnosis is the RN’s clinical judgment regarding the resident’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the resident is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications; for example, respiratory infection is a potential hazard to an immobilized resident. The diagnosis is the basis for the nurse’s care plan.

Outcomes and Planning
Based on the assessment and diagnosis, the RN sets measurable and achievable short- and long-range goals for the resident that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the resident’s care plan so that nurses and other health professionals caring for the resident have access.

Implementation
Nursing care is implemented according to the care plan and ensures continuity of care.

Evaluation
The resident’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed. The care plan should be unique to the individual resident. Remember, cookie cutter and check-off care plans do not support the intent of the regulation.

For more MDS news, download the Winter 2018 Issue of our MDS Quarterly newsletter.

MDS Quarterly Newsletter Winter 2018