This letter outlines the requirements for nursing homes and other healthcare facilities to develop and implement comprehensive care plans for each resident that are person-centered, culturally-competent, and trauma-informed. The care plans must include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, as well as any services that would otherwise be required but are not provided due to the resident's exercise of rights. The care plans must also reflect the resident's goals for admission and desired outcomes, as well as any specialized services or rehabilitative services the nursing facility will provide as a result of PASARR recommendations. In addition, the care plans must include interventions to enable each resident to meet their objectives, and must be developed using the Minimum Data Set (MDS) and any triggered Care Area Assessments (CAAs). Nursing homes and other healthcare facilities must take the necessary steps to ensure their care plans meet these requirements.

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