Care Plans

F656 — Develop and Implement Comprehensive Care Plan

Failure to develop and implement an individualized, person-centered comprehensive care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs.

Reg cite · 42 CFR 483.21(b)(1)(2) 188 surveys in corpus 36 states

What surveyors look for

  1. Initial care plan within 48 hours of admission, full IDT care plan within 7 days after MDS completion
  2. Interventions are specific, measurable, time-bound, and individualized — not generic 'monitor and report'
  3. Resident/family participation documented (signature, video, attestation)
  4. Care plan revised after every significant change, every quarterly review, after falls/wounds/behavior events

Common gotchas

  1. Care plans copy-pasted from previous resident or template language
  2. Falls intervention listed as 'fall mat' but no fall mat present in room
  3. Goals like 'will not fall' instead of measurable goals like 'will use call light prior to ambulation in 80% of opportunities'
  4. Care plan not updated after wound progressed from Stage 2 to Stage 3

Real survey examples

From CMS-published 2567s in our corpus. Resident identifiers redacted.

AL 2023-03-02
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, Resident Identifier (RI) #103's medical record review, and a facility policy titled Care Plan, Comprehensive, the facility failed to ensure Employee Identifier (EI) #7 Certified Nursing Assistant (CNA), followed RI #103's care plan intervention to have two persons assistance for transfer…
AL 2023-03-02
-Develop/Implement Comprehensive Care Plan. The immediate jeopardy began on [date] and continued until [date], when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Total census 50. Findings Include: A facility policy titled, Care Plan, Comprehensive, implemented 09/2016 and last reviewed/revised 01/2023 documented: Purpose: . The facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing, and mental/psychosocial needs that are ide…
AL 2023-03-02
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Policy: .3 . f. Resident specific interventions that reflect the resident's needs and preferences . RI #103 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's Disease and Macular Degeneration. RI #103's annual Minimal Data Set (MDS), with an Assessment Reference Date of [date] assessed RI #103 as a two person assist with transfers. RI #103's care plan for being at high risk for falls related to impaired balance and total dependence on two staff and mechanical lift for transf…
AL 2023-03-02
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few make sure she/he was in the sling properly and it was a safe transfer. EI #7 further said, RI #103 sustained a laceration and was told he/she may have a C2 fracture. EI #7 said the care plan was to be followed to avoid situations such as falling and having an injury, such as the case with RI #103. EI #7 confirmed this fall could have been avoided if two people assisted with the lift. On [date] at 12:30 PM, an interview was conducted with EI #8, Registered Nurse (RN). EI #8 reported she went to RI #103's ro…
AL 2023-03-02
Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few This deficient practice was cited as a result of the investigation of complaint/report number AL00042944. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to Alabama Department of Public Health (ADPH) [date] and conducted an investigation. 2. Completed in-service with staff on following care guides with transfer using the mechanical lift. Completed [date]. 3. The Care Plan Coordinator and designee reviewed…

Accepted POC examples

Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.

Related F-tags

F657 F684 F689

Just got cited at F656? Draft your POC in minutes.

Upload your 2567, choose your state, and get a CMS-compliant POC draft you can edit and submit.

Start the drafter