08/20/2026
Survey Tip of the Week: Comprehensive Care Plans
Recent citations under F656, Comprehensive Care Plans, highlight the importance of ensuring the care plan addresses specialized services, equipment, and interventions identified as necessary for the residents. The comprehensive person-centered care plan must include measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified through the comprehensive assessment. The care plan must also describe the services and interventions that will be provided to attain or maintain the resident’s highest practicable level of well-being.
Recent survey citations have included failure to address:
- Non-invasive mechanical ventilation
- Power wheelchair use, including use of a seatbelt
- Transfers using a mechanical lift
- Turning and repositioning as an intervention to prevent pressure ulcers
- PICC line care and management
- Wound VAC therapy
Importantly, care planning is not just an F656 issue. The care plan is woven throughout the federal requirements and is an important source of evidence when surveyors investigate compliance with many F-tags. When a negative outcome, change in condition, or resident-specific risk is identified, surveyors may review the care plan to determine:
- Was the resident’s risk or need identified?
- Was there an appropriate intervention in place?
- Was the intervention individualized to the resident?
- Did staff know what they were expected to do?
- Was the care plan actually implemented?
- Was the plan revised when the resident’s condition, needs, or outcomes changed?
The Long-Term Care Survey Process (LTCSP) also reinforces the connection between the written care plan and the care actually provided. When concerns are identified in areas such as pressure ulcers or incontinence, surveyors are instructed to conduct continuous observations as necessary to determine whether appropriate care and services are being provided in accordance with the resident’s care plan.
