Regulatory expectations never stop evolving, and neither should the way we prepare for them. That’s why our CMSCG Ftag of the Week series is back with a renewed focus on practical insights that help skilled nursing providers stay survey‑ready every day. Each week, we break down a specific F‑Tag, highlight what surveyors are looking for, and share actionable guidance your team can use to strengthen compliance and improve resident outcomes.
Whether you’re a seasoned compliance leader or building your QAPI process from the ground up, this series is designed to keep you informed, proactive, and aligned with CMS requirements. Check back weekly as we continue to translate regulatory language into real‑world strategies that support quality care and operational success.
This week, we’re looking at a topic that addresses a “necessary evil” that many nursing home staff are not fond of . . . care planning. Unfortunately, it’s an area where many staff struggle, so in this post, we’re providing some practical guidance and examples to help your staff succeed.
F656 – Develop/Implement Comprehensive Care Plans
F656 requires that a facility develops and implements a comprehensive, person-centered care plan for each resident. The care plan must include measurable objectives and timeframes to meet the resident’s needs which have been identified through the comprehensive assessment.
Before we go any further, let’s pause to review some of the key words since they’re really what this requirement is all about:
“Person-Centered”
This is one of the biggest areas that’s missed when care planning. For F656, the care plan is not just a list of generic interventions. The care plan must reflect who the resident is as a person – not just their diagnoses or behaviors. When we are developing a person-centered care plan, in conjunction with the resident/representative, we are considering the individual resident’s:
- Preferences
- Routines
- Goals
- Strengths
- Choices
These factors contribute to the interventions and approaches that staff use for each resident. Do we need to consider things such as daily routine preferences, cultural needs, communication styles/needs which are unique to each resident?
Template interventions from your EMR care plan library often don’t differentiate anyone or anything – the opposite of person-centered.
“Measurable objectives and timeframes”
If a goal doesn’t include numbers, counts, comparisons or observable actions to help you understand if it was achieved or not, then it’s not measurable. Here’s two thoughts and examples to help clarify this concept:
Example 1:
Non-measurable: “Improve intake”
vs.
Measurable: “Eat at least 50% of each meal x 7 days.”
If you don’t put a number and a timeframe on it, you can’t tell if you’ve achieved it or not. Goals can’t be subjective. You also need supporting information to determine if a goal was achieved. It’s the difference between an aide telling you, “Oh yes, she’s eaten a lot more” but there’s nothing to back that up vs. the aide making a similar statement and there’s routine meal consumption documentation to support the statement.
Example 2:
Non-Measurable: “Resident will have fewer behaviors.”
That’s a pretty vague example and there’s no timeframe to determine if progress towards the goal is being achieved.
Measurable: “Resident will demonstrate no more than two verbal outbursts per shift x7 days, as evidenced by behavior tracking documentation.”
This allows staff to keep track – and document – progress towards this goal. Is this what your goals look like?
What All Needs to be Included
F656 states that the CCP needs to describe the following:
- Services to be provided
- Any services that are required but are not being provided due to the resident’s preference/ right to refuse treatment
- Specialized services or specialized rehab services which must be provided as a result of a PASRR recommendation.
- Resident’s goals for admission and desired outcomes
- Resident’s preference and potential for future discharge. Note that facilities are required to document in the medical record if the resident’s potential for return to the community was assessed and if any referrals were made to local contact agencies and/or other appropriate entities to facilitate discharge.
- Discharge plans
There’s lots more to cover, so check back next week related to assessments, care planning considerations and some key areas to include in the CCP.
Catch-up on Ftag of the Week Posts:
In the meantime, you can also review CMSCG Ftag of the Week posts for some of the areas noted above:
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