A Baseline Care Plan is an initial, concise care plan developed within 48 hours of a resident's admission into a Long-Term Care (LTC) facility. Its primary purpose is to ensure the immediate care needs of the resident are met while a more comprehensive care plan is being developed. The Centers for Medicare & Medicaid Services (CMS) regulations, specifically under 42 CFR §483.21(a)(1-3), mandate the development of a Baseline Care Plan to include essential information that addresses the resident's critical needs. Here, we detail the components included in a Baseline Care Plan:

1. Initial Goals for Care

The Baseline Care Plan must outline initial, immediate goals for the resident's care. These goals are based on the preliminary assessment conducted upon admission and focus on ensuring the resident's immediate health, safety, and well-being.

2. Physician's Orders

This includes a summary of the resident's current physician's orders that address the resident's health care needs upon admission. It encompasses medications, dietary orders, therapy services, and any other medical interventions required to meet the immediate care needs of the resident.

3. Dietary Information

Critical dietary information is a mandatory inclusion, detailing any specific dietary needs, preferences, allergies, or restrictions the resident has. This ensures the resident's nutritional status is supported from the moment they enter the facility.

4. Services and Treatments

A summary of the medical and nursing services and treatments that will be provided to address the resident's immediate needs is included. This may cover wound care, mobility assistance, or other personalized nursing interventions necessary for the resident's care.

5. Advance Directives

If available, the Baseline Care Plan should document the resident's advance directives or any preferences regarding end-of-life care. This ensures that the resident's wishes are respected and followed from the outset.

6. Resident and Representative Involvement

The plan should reflect the extent to which the resident and their representative (if applicable) were involved in the development of the Baseline Care Plan. This involvement is crucial for ensuring that the care plan aligns with the resident's preferences and goals.

7. Contact Information

Contact information for the resident's family or representative, as well as the primary healthcare provider, should be included to facilitate communication and coordination of care.

Implementation and Review

While the Baseline Care Plan provides immediate care guidance, it is intended to be a temporary tool until a comprehensive care plan, developed from a full assessment including the MDS, is completed. The comprehensive care plan, which should be developed within 7 days following the completion of the comprehensive assessment, will replace the Baseline Care Plan and provide a detailed roadmap for the resident's long-term care and services.

Compliance with Federal Regulations

The inclusion of these components in the Baseline Care Plan is not only best practice but also a regulatory requirement under CMS guidelines. These regulations ensure that residents receive personalized, immediate care that considers their specific needs and preferences from the moment they enter the LTC facility.

By covering these essential areas, the Baseline Care Plan acts as an initial safeguard, ensuring that the resident's critical care needs are identified and addressed promptly, setting the stage for the development of a more detailed and individualized comprehensive care plan.