Ch. 7, § 4. Standards for Resident Services

(a) Upon admission, the Mountain View SNF shall begin person-centered care planning pursuant to 42 CFR 483.21, as driven by the Minimum Data Set (MDS) assessment administration process. (i) The interdisciplinary team shall develop a baseline person-centered care plan within forty-eight (48) hours of admission that meets professional standards of quality care. (ii) The Mountain View SNF shall develop a comprehensive care plan within seven (7) calendar days after completion of the comprehensive assessments. (iii) The Mountain View SNF shall share summary information included in the baseline and comprehensive person-centered care plans with the resident upon request. (iv) The Mountain View SNF shall ensure person-centered care plans incorporate strengths, needs, personal and cultural preferences, and the resident's preference and potential for discharge. The Mountain View SNF shall also ensure services outlined in the person-centered care plan translate into medical treatment, nursing related treatment, behavioral based approaches, applicable therapies, and activity preferences. (b) The resident's interdisciplinary team shall review the person-centered care plan after each subsequent assessment and in accordance with the MDS care planning schedule.