Care Intake Standards Map (LTC)

A visual, step‑by‑step guide outlining what should occur during admission, assessment, care planning, and early monitoring in long‑term care settings.

Care Intake Standards Map (LTC)

The Care Intake Standards Map outlines what should occur during admission, assessment, care planning, and early monitoring in long-term care settings. This guide breaks down the required steps a facility must follow from the moment a resident is admitted, helping attorneys quickly identify breakdowns and whether the facility met its obligations during the critical phase of care.

Use this map during case intake, breach evaluation, and timeline reconstruction.

Admission Process (What Should Happen)

✔ Pre‑Admission Review
Review hospital discharge summary
Review medication list
Identify immediate risks
Confirm equipment needs
Ensure staff readiness
✔ Admission Assessment (Within Hours)
Full head‑to‑toe assessment
Baseline vitals
Skin assessment
Cognitive and functional evaluation
Pain assessment
✔ Immediate Interventions
Fall precautions
Skin protection
Hydration/nutrition support
Medication reconciliation
Monitoring schedule established

Care Plan Development

✔ Interdisciplinary Team Meeting
Nursing
Therapy
Dietary
Social services
Medical provider
✔ Individualized Care Plan Must Include
Identified risks
Specific interventions
Measurable goals
Monitoring frequency
Resident preferences
✔ Communication to Staff
CNAs
Nurses
Therapy
Dietary
Activities

Early Monitoring (First 72 Hours)

✔ Required Monitoring
Vitals
Pain
Skin integrity
Hydration/nutrition
Behavioral changes
Medication effect
✔ Required Documentation
Shift‑by‑shift notes
CNA flow sheets
Nursing assessments
Physician notification

Common Breakdown Points

Missed admission assessment
Incomplete skin assessment
Failure to identify risks
Delayed care plan development
Poor communication to staff
Missed early monitoring
Documentation gaps

Long-Term Care Intake Standards Mapping Clarifies Admission Duties and Early Risk Exposure

Many long-term care failures originate at admission, when facilities accept residents without appropriate assessment, capacity, care planning, or risk mitigation. The LTC Care Intake Standards Map evaluates pre-admission screening, admission assessments, care plan development, staffing alignment, and documentation against CMS nursing facility requirements, state regulations, and accepted long-term care standards. Our clinical-legal team identifies intake failures, inappropriate admissions, unmet care needs, and early compliance gaps that drive downstream liability and regulatory exposure.

Submit Records for LTC Intake Standards Review
HIPAA-secure intake • Admission & intake compliance mapping • Standard 7-day delivery