07/31/2025

Survey Tip of the Week: Initial Goals for Care

Throughout 2025, F-tag 655 (Baseline Care Plans) has been cited frequently in Ohio nursing homes. A common issue noted by surveyors is the failure to adequately identify and address a resident’s initial care needs upon admission.

Citations may occur when a resident experiences a negative outcome or does not receive the necessary services—and the baseline care plan either omits key risks or fails to reflect those needs.

Federal regulations require that a baseline care plan be both completed and implemented within 48 hours of admission. This critical window is intended to ensure continuity of care, improve communication among staff, and reduce the risk of adverse events during a resident’s most vulnerable time: the first days after arriving.

Additionally, the resident—and their representative, when applicable—must receive a written summary of this plan to help them understand how care and services will be delivered from the start.

Providers are encouraged to review their admission and care planning processes to ensure compliance and, most importantly, support safe, person-centered care.

The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary.

Baseline care plans are required to address, at a minimum, the following: 

• Initial goals based on admission orders.
• Physician orders.
• Dietary orders.
• Therapy services.
• Social services.
• PASRR recommendation, if applicable. 

Because the baseline care plan outlines the interim strategies for addressing a resident’s immediate needs, it must be updated if there are any significant changes in the resident’s condition or needs before the comprehensive care plan is developed. In keeping with professional standards of quality care, these updates should reflect any necessary changes in approach.

Facility staff are responsible for putting the baseline care plan into action, using the outlined interventions to help the resident meet the identified goals and objectives.

Facilities should also routinely monitor compliance using the surveyor guidance outlined in the State Operations Manual Appendix PP.  Additionally, the survey pathways can be found in the Survey Resources zip file on the CMS Nursing Home webpage and under the downloads section on this CMS webpage. LeadingAge Ohio has provided survey tips to help navigate the changes in the revised QSO-25-14- NH memo.  The previously provided survey tips can be accessed on the LeadingAge Ohio webpage under the Communications tab, then The Source tab. CMS has updated the survey resources on the CMS Nursing Home webpage in accordance with the revised QSO-25-14- NH memo. LeadingAge has developed webinars and resources on the requirements of participation which are located on the LeadingAge learning hub. LeadingAge continues to add QuickCasts on the regulatory groups. Updated resources have also been added on the Nursing Home RoP Tools and Resources webpage.  

For more information about the requirements of participation and citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the August 13 call at 11:00AM. LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you would like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.