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CMS proposes individualized care plan for long-term care patients

September 23, 2015
by Nicole Stempak, Associate Editor
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The Centers for Medicare & Medicaid Services (CMS) has proposed new requirements for long-term care (LTC) facilities that wish to participate in Medicare and Medicaid programs.

It’s the first comprehensive change to the conditions of participation (CoPs) since 1991 and is part of the agency’s larger push to deliver person-centered care.

“Therefore, we are reviewing regulations in an effort to improve the quality of life, care, and services in LTC facilities, optimize resident safety, reflect current professional standards, and improve the logical flow of the regulations,” states the proposed rule. “Many of the revisions are aimed at aligning requirements with current clinical practice standards to improve resident safety along with the quality and effectiveness of care and services delivered to residents.”

CMS estimates the total projected cost of this rule would be $729.5 million in the first year. This results in an estimated first year cost of about $46,491 per facility and a subsequent-year cost of $40,685 per facility on 15,691 facilities.

The proposed rule includes the following major provisions:

Transitions of Care

A transfer of discharge must be documented in the clinical record and include specific information, such as history of present illness, reason for transfer and past medical/surgical history. The transfer of discharge must be exchanged with the receiving provider or facility when a resident is transferred. CMS has not proposed a specific form, format, or methodology for documentation.

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.

Physician Services

A physician, a physician assistant, nurse practitioner or clinical nurse specialist must conduct in-person evaluation of a resident before an unscheduled transfer to a hospital.

Nursing Services

Nursing staff must satisfy a competency requirement based on a facility assessment, which includes but is not limited to the number of residents, resident acuity, range of diagnoses and the content of care plans.

Behavioral Health Services

Staff must have the appropriate competencies and skills to provide behavioral health and services, which include caring for residents with mental and psychosocial illnesses and implementing non-pharmacological interventions.

Pharmacy Services

A pharmacist must review a resident’s medical chart at least every six months. A pharmacist must also review drug regimens for new residents, when a prior resident returns or is transferred and when the resident has been prescribed or is taking a psychotropic drug, an antibiotic or any drug the quality assessment and assurance (QAA) committee has requested be included in the pharmacist’s monthly drug review.

Food and Nutrition Services

  • Clarification that a “qualified dietitian” is someone who is registered by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics or who meets state licensure or certification requirements. Dietitians hired or contracted with prior to the effective date of these regulations are allowed up to five years to meet the new requirements.
  • At a minimum, a director of food and nutrition must be a certified dietary manager, certified food service manager, or have a certification for food service management and safety from a national certifying body or have an associate’s or higher degree in food service management or hospitality from an accredited institution of higher learning.


  • A facility-wide assessment must be conducted and documented at least once a year to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.
  • This assessment must include the facility’s resident population (the number of residents, overall types of care and staff competencies required by the residents, and cultural aspects) resources (i.e., equipment and overall personnel) and a facility-based and community-based risk assessment.

Quality Assurance and Performance Improvement (QAPI)

LTC facilities must develop, implement and maintain an effective comprehensive, data-driven QAPI program that focuses on systems of care, outcomes of care and quality of care.