Q:
I am having difficulty keeping up with care plan updates. What are some tips and strategies to keep care plans up-to-date?
A:
Maintaining timely and accurate updates to resident care plans is essential not only for delivering quality, person-centered care, but also for ensuring compliance with regulatory standards, including F656, which addresses requirements to develop and implement a comprehensive care plan. Failure to keep care plans current can result in inconsistencies in care delivery and potential citations during surveys. To proactively avoid F656 deficiencies, facilities can implement a variety of practical strategies targeting streamlined care plan updates and improved interdisciplinary communication.
1. Create a Routine for Review
- Set a daily routine for care plan reviews. Tie reviews into existing workflows—such as reviewing notes and orders every morning.
- Use a checklist or dashboard to quickly spot which care plans are due for review or those that haven’t been updated recently.
2. Leverage Interdisciplinary Meetings
- Use daily stand-ups, weekly rehab meetings, or huddles to gather and update information in real time. Designate someone to note care plan changes as they’re discussed.
- Encourage team members to flag any changes they observe during care that might warrant a care plan update.
3. Assign Responsibilities Clearly
- Delegate parts of the care plan (e.g., fall risk, nutrition, ADLs) to the most appropriate discipline for development, so that no one person is responsible for the entire plan.
4. Involve the Resident and Family
- Incorporate feedback gathered during routine conversations to make updates more meaningful and person-centered.
5. Audit and Track
- Perform mini-audits weekly to catch outdated information.
6. Use Tech Wisely
- Set alerts or reminders in your EMR for review intervals.
- If your system tracks changes in condition (such as weight loss, falls, or hospitalizations), use those triggers to cue care plan revisions.
By implementing these strategies, care teams can more effectively manage care plan updates, reduce the risk of non-compliance with F656, and most importantly, ensure that residents receive care that accurately reflects their current needs and preferences. Staying proactive, organized, and collaborative is key to maintaining comprehensive and compliant care plans that support both quality outcomes and regulatory success.
Resources:
Center for Medicare and Medicaid Services. (2024, October). MDS 3.0 RAI User’s Manual. Retrieved from https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual
Center for Clinical Standards and Quality/Quality, Safety, & Oversight Group. QSO-25-14-NH. (2025, March). Revised Long-Term Care (LTC) Surveyor Guidance. Retrieved from https://www.cms.gov/files/document/qso-25-14-nh.pdf
Written By:
Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant
Proactive LTC Consulting
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