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Developing Person-Centered Care Plans

June 09, 2020
Healthcare Consulting By Terry Raser, Senior Consultant

The Centers for Medicare & Medicaid Services (CMS) and the Department of Health (DOH) surveyors are requiring nursing facilities to develop person-centered care plans. According to the State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities, the definition for person-centered care is “to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.”




The State Operations Manual, §483.21(b), provides more details about person-centered care and developing the care plan. Person-centered care includes making an effort to understand:

  • What the resident is communicating.
  • What is important to the resident.
  • The resident’s prior life.

Identifying person-centered care starts on admission with reviewing hospital information, but most importantly, communicating with the resident and representative and building a picture of the resident’s life before their current illness, injury, or exacerbation. What did their life look like before? Taking the time to review the resident’s life before admission helps staff to understand why the resident responds a certain way or displays certain behaviors that may present during the first few days of admission. 

My husband and I cared for my mother-in-law for two years before her care required assisted living. As an experienced nurse, I took the time to write down in care plan format her needs, strengths and routine prior to admission. I did this so that she could have a smooth transition into a different living environment, surrounded by people she was not familiar with and meals she may not eat. Writing this person-centered care plan gave the staff an idea of her prior life routine and made the transition much easier, not only for her but the family as well.

It is imperative to give the resident the right to drive their care. If a resident has dementia or impaired cognition and cannot express themselves fully, identifying prior routine is invaluable to writing a person-centered baseline care plan which is required to be developed and implemented within 48 hours of admission.

Below are some of the regulations that guide the person-centered care plan:

  • F655, “Baseline Care Plan,” §483.21(a) effective 11/28/19. For more information on the baseline care plan, read “Understanding the Baseline Care Plan and Summary.”
  • F553, “Right to Participate in Planning Care,” §483.10(c)(2).
  • F656, “Develop/Implement Comprehensive Care Plan,” §483.21(b). Information about Care Area Assessments (CAAs) can also be found under this F-Tag.
  • F657, “Care Plan Timing and Revision,” §483.21(b)(2). Who Needs to be Involved in the Care Plan?
  • F658, “Services Provided Meet Professional Standards,” §483.21(b)(3).

Tips for Developing the Person-Centered Care Plan:

  • Use the resident’s name rather than the word “resident.”
  • Set small obtainable goals that the resident wants to meet.
  • Refrain from using canned care plans.
  • Question nursing assistants and housekeepers on resident routines.
  • Address care plan strengths as well as weaknesses.

If your facility needs education or mentoring on developing person-centered care plans, LW Consulting, Inc. can help.


For more information, call Terry Raser at 610-314-5095 or email at

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