F656 Develop/implement comprehensive care plans is the #5 most cited deficiency nationally. This week’s blog examines what you need to know about the regulatory requirements related to F656 and how to avoid issues commonly cited by surveyors.

There are five standard steps in the nursing process which guide the development of the nursing care plan: Assessment, Diagnosis, Planning, Implementation, and Evaluation. Thorough, accurate and timely completion of resident assessment should guide the development of a care plan that paints a true picture of the resident’s preferences, choices, goals and care needs at any given time. Care plans should describe medical needs, nursing needs, physical needs, mental and psychosocial needs, preferences and how the facility will assist in meeting these needs and preferences. Regardless of the assessment schedule, when changes are noted in a resident’s care needs, a new assessment can and should be completed and the care plan updated to reflect the new information.

Resident centered goals which reflect the resident’s goals for admission and desired outcomes must be developed with documentation of the planned interventions to be taken take to meet those goals. Resident and/or family/resident representative input is essential to ensure that goals are meaningful. In addition, goals must be S.M.A.R.T.: Specific, Measurable, Achievable, Relevant and Timely. Interventions should be relevant to the goal you are trying to achieve and take into account the resident’s personal preferences, routines, current abilities, and limitations.

For effective implementation, effective systems to ensure that each member of the interdisciplinary team understands their role in carrying out the care plan, with documentation to support the adherence to the specified care plan interventions.  Then, ongoing evaluation of the effectiveness of the care plan should be completed, with any changes in the resident’s abilities, conditions, or goals reflected in updates to the care plan in a timely manner.

So how does a care team manage to stay on top of the constantly changing resident goals, abilities, and concerns?

    • Daily review of nursing notes can help identify areas of concern
    • Daily team meetings (such as stand-up or stand-down meetings) are excellent places for staff to discuss care plan changes that may need to be implemented
    • Routine Rehab meetings to include nursing staff as well as social services to discuss resident changes, whether positive or negative
    • Team huddles to disseminate information regarding care plan changes to front line staff
    • Encouragement of staff from all disciplines to bring resident care concerns to management to discuss
    • Rounding on units to physically observe care and take note of any discrepancies between the care plan and actual practice
    • Regular discussion with the resident and family as to how they feel progress toward selected goals is going and revision as necessary

In short, the care plan is your facility guide for each resident and their care needs. Having accurate, thorough, and relevant care plans is critical and will ensure that staff and residents are all working towards common goals for care.

Make plans to join us for these upcoming Care Plan focused webinars:

    • May 25, 2022 Becoming a CAA and Care Planning Maestro— part of the MDS Mastermind Series. This session will focus on the care planning process and improving key components of care plan effectiveness: comprehensive, timely, and person centered, as well as offering strategies for bridging the gap between MDS Care Area Assessments and planning care around resident’s goals and preferences. Learn more
    • June 7, 2022 Analysis of Top 10 Citations in the Nation: F656 Develop/Implement Comprehensive Care Plans for a deep dive review of Survey Procedures related to this topic, as well as examples of IJ citations and recommended action steps to avoid the same or similar issues. Learn more and register at: Survey Success! Avoiding Top Citations – Proactive Medical Review





Judy Caffrey, RN

Clinical Consultant

Learn more about the rest of the Proactive team.