Every SNF note ties to the resident’s care plan, and the care plan has a defined cadence with its own F-tags. Home health links to a physician plan of care; the SNF links to a three-stage, interdisciplinary, person-centered plan that surveyors examine directly.
Stage
Requirement
F-tag
Baseline care plan
Within 48 hours of admission: initial goals from admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendation if applicable. A written summary is given to the resident/representative by the time the comprehensive plan is done. (48 hours is 48 hours, not 2 business days.)
F655
Comprehensive person-centered plan
Developed by the IDT with the resident/representative within 7 days of completing the comprehensive assessment (≤21 days from admission). Measurable objectives; resident goals for admission and discharge.
F656
Review & revision
The IDT reviews and revises after each assessment (comprehensive and quarterly) and whenever status changes. Every note references a named problem/goal.
F657
The linkage habit
End the skilled portion of a note with the named goal it advances — e.g., “ties to care-plan Problem #3 (impaired skin integrity), goal: no new pressure injury.” A note that floats free of the care plan is both a coverage weakness (no plan linkage) and a survey weakness (F656/F657).
