Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to ensure that a baseline care plan summary was provided to the resident or their representative for three of the six sampled residents. According to the facility's policy, a baseline care plan should be developed within 48 hours of admission and include necessary healthcare information, initial goals based on various orders, and a written summary provided to the resident or representative. However, for Residents 2, 3, and 4, there was no evidence that such summaries were provided, despite the baseline care plans being developed on specific dates. The deficiency was confirmed during an interview with the Administrator, who acknowledged the lack of evidence that the baseline care plan summaries were provided to the residents or their representatives. This failure to provide the required documentation was noted as a violation of the facility's policy and the regulatory requirement under 28 Pa. Code 201.18 (b)(1) Management.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Residents #2, 3, and 4 have been given copies of their individual care plans. 2. All new admissions will receive a summary of their baseline care plan. An audit of all new admissions in the last two weeks will be conducted to ensure that a summary of the baseline care plan was received by the resident and/or responsible party. 3. The interdisciplinary team will be re-educated on the center's Person-Centered Care Plan Policy. 4. A weekly audit for 4 weeks of all new admissions and then biweekly for 2 months of random new admissions will be conducted to verify that residents/responsible parties are given a summary of their baseline care plan. Results of the audits will be presented to the center's QAPI Committee for review and follow up actions as recommended.