Understanding Interpretive Guidance for F656: Comprehensive Care Plans

Understanding Interpretive Guidance for F656: Comprehensive Care Plans

Care planning is a fundamental component of quality patient care, offering an organized structure for identifying resident needs through comprehensive assessment. So far in Calendar Year 2025, F656 was cited 4,087 times nationally, with 67 Immediate Jeopardy (IJ) citations and 81 harm-level deficiencies, highlighting the importance of compliance with this regulation. The person-centered care plan ensures that each resident receives individualized services and care—serving as a dynamic roadmap that directs the care team’s efforts, with the resident actively guiding their own journey.

Let’s review key aspects of a successful care planning process…

Key Elements of a Comprehensive Care Plan

The comprehensive care plan should reflect the resident’s goals, preferences, needs, and strengths as identified in the comprehensive assessment. To support residents in achieving their highest practicable well-being and preventing avoidable decline, care plans should integrate multiple assessment tools beyond the standard resident assessment. Collaboration among residents, caregivers, interdisciplinary team (IDT) members, and families remains essential.

All necessary services should be incorporated into the care plan, including, but not limited to:

• • Nursing services
  • Specialized rehabilitative services
  • Behavioral health services
  • Social services
  • Dietary services
  • Pharmacy services
  • Activities and recreational programs

Care plans should also account for risk factors, resident preferences, rights, advance directives, physician orders, and professional standards of practice. Discharge planning must align with resident wishes, including any referrals to local agencies or appropriate support services.

Person-Centered Goals and Interventions

Person-centered care prioritizes the resident’s autonomy, ensuring they retain control over their daily lives and care decisions. This includes choices regarding:

• • Daily routines (e.g., mealtimes, sleep schedules, personal activities)
  • Clothing and personal preferences
  • Social engagement and recreational activities

Care plans must establish measurable goals with clear timeframes, enabling staff to assess progress and make necessary adjustments. Continuous evaluation ensures the plan remains responsive to evolving resident needs, ensuring changes are documented and implemented promptly.

Care Plan Formats and Compliance

While no specific format is mandated for care plans, facilities may use various structures, including “I” care plans or problem/focus-based models derived from Minimum Data Set (MDS) responses or nursing diagnoses. Regardless of format, the care plan must accurately reflect assessment findings, goals, and resident-specific considerations.

Resident and Representative Participation

Active participation of the resident and/or their representative in care planning should be documented in the medical record. If a resident or representative declines involvement, the facility must document all efforts made to encourage participation. Ongoing discussions should ensure informed decision-making and allow for modifications to the care plan as resident preferences evolve.

PASRR Integration

For residents subject to Level II PASRR evaluations due to potential mental illness (MI) or intellectual/developmental disabilities (ID/DD), care plans must incorporate specialized services as recommended. If the IDT disagrees with PASRR findings, documentation should outline any discrepancies and the rationale for alternative interventions. If a resident chooses a different approach, this preference must be documented.

Implementation and Staff Accountability

Consistency between the care plan and daily care implementation is essential. Staff must apply interventions uniformly throughout the day, ensuring alignment with medical records and resident observations. For example, if a care plan specifies the use of a Hoyer lift for transfers, all shifts must adhere to this requirement to maintain compliance. Facilities must also have processes in place to educate direct care staff on care plan details, including updates, and ensure accessibility of care plans for frontline workers.

Addressing Treatment Refusals

When a resident refuses treatment, the care plan team should document the facility’s efforts to explore alternative approaches. Staff should investigate the reasons for refusal, such as pain or discomfort, and implement interventions accordingly. Residents must receive education on the risks and benefits of treatment options, with caregivers taking proactive steps to minimize potential negative outcomes resulting from refusals. The resident’s decision-making capacity should also be periodically reassessed.

Ensuring Compliance with F656

To maintain regulatory compliance, facilities should conduct quality assurance audits focusing on:

• • Care Area Assessment triggers and rationales for proceeding with care planning
  • Timely completion and updates to care plans
  • Consistency between care plans, medical records, and resident observations
  • Interdisciplinary communication and resident engagement

Monitoring efforts should evaluate revisions, PASRR compliance, discharge planning, adherence to professional standards, and resident participation in care decisions. Continuous engagement with residents and direct care staff will ensure that care plans truly reflect person-centered care objectives and best practices.

Next Steps: Join Proactive for the upcoming virtual workshop, Dynamic DON. This 6-hour virtual workshop will take place on March 31st and April 1st and focus on skill building for serving effectively as the Director of Nursing with emphasis on effective leadership and staff engagement, nursing operations and systems of care for common conditions treated in the LTC setting. Consider a 3rd party Care Plan review with Proactive as part of your 2025 QAPI work plan. Contact Proactive to learn more.

Resources:

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

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