Recently the Centers for Medicare & Medicaid Services (CMS) responded to questions regarding the baseline care plan. The question and answer are detailed below:
Question: Within what timeframe should a provider give the family a written summary baseline care plan?
Answer: The baseline care plan must be made in 48 hours. However, it is unclear how much time a provider has to give the family a written summary of plan.
CMS updated its Frequently Asked Questions to include the following:
“At F655, the guidance states, ‘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.’ This means the resident or their representative must be provided a written summary before the completion of the comprehensive care plan. Additionally, if the comprehensive assessment identifies changes which would result in a different approach or goal on the comprehensive care plan, these changes must also be reflected in the summary. This is reflected in the following guidance, which goes on to say ‘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.’
‘Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident’s care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.’”
Question: Can you please confirm that a Care Plan review is required after each assessment for both OBRA and PPS assessments (with the exception of the discharge MDS)? And does this review require documentation that the review was completed?
Answer: “The regulation at 483.21(b)(2)(iii) (F657) states: ‘§483.21(b)(2) A comprehensive care plan must be— … (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.’ Draft interpretive guidance at F657 states, ‘After each assessment’ means after each assessment known as the Resident Assessment Instrument (RAI) or Minimum Data Set (MDS) as required by §483.20, except discharge assessments.’ Additionally, you ask if the care plan review requires documentation. The expectation is that facilities can demonstrate that they have reviewed the care plan, even if no revisions are required. How facilities demonstrate this is up to each facility.’”