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Comprehensive Person-Centered Care Planning
- Facilities must develop a baseline care plan for each resident within 48 hours of their admission that includes care instructions.
- A nurse aide, a member of the food and nutrition services staff and a social worker are required members of the interdisciplinary team that develops the comprehensive care plan.
- The plan must include any specialized services or specialized rehabilitation services the nursing facility will provide as a result of Preadmission Screening and Resident Review (PASARR) recommendations.
- As required by the IMPACT Act, facilities must include discharge planning requirements for LTC facilities. The summary must include a reconciliation of all discharge medications with pre-admission medications (both prescribed and over-the-counter). The post-discharge plan of care should summarize what arrangements have been made for the resident’s follow-up care and any post-discharge medical and non-medical services.