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§483.21(b)(3) Comprehensive Care Plans

The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—

(i)  Meet professional standards of quality.

INTENT §483.21(b)(3)(i)

The intent of this regulation is to assure that services being provided meet professional standards of quality.

GUIDANCE §483.21(b)(3)(i)

“Professional standards of quality” means that care and services are provided according to accepted standards of clinical practice.  Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature.  Possible reference sources for standards of practice include:

  • Current manuals or textbooks on nursing, social work, physical therapy, etc.
  • Standards published by professional organizations such as the American Dietetic Association, American Medical Association, American Medical Directors Association, American Nurses Association, National Association of Activity Professionals, National Association of Social Work, etc.
  • Clinical practice guidelines published by the Agency for Healthcare Research and Quality.
  • Current professional journal articles.

NOTE: Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the clinical assessment process is more fluid and should be ongoing. The lack of ongoing clinical assessment and identification of changes in condition, to meet the resident’s needs between required RAI assessments should be addressed at 483.35 Nursing Services, F726 (competency and skills to identify and address a change in condition), and the relevant outcome tag, such as 483.12 Abuse, ?Quality of Life, 483.25 Quality of Care, and/or 483.40 Behavioral Health..

PROCEDURES AND PROBES §483.21(b)(3)(i)

There is no requirement for the surveyor to cite a reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the standard of practice that has not been followed related to care and services provided within professional scopes of practice, such as failure of nursing staff to assess a change in the resident’s condition. However, in cases where the facility provides a reference supporting a particular standard of practice for which the surveyor has concerns, the surveyor must provide evidence that the standard of practice the facility is using is not up-to-date, widely accepted, or supported by recent clinical literature. Such evidence should include a citation for the reference or source (e.g., current textbooks, professional organizations or clinical practice guidelines) for the current standard of practice from which facility deviated.

If a negative or potentially negative resident outcome is determined to be related to the facility’s failure to meet professional standards and the team determines a deficiency has occurred, it should also be cited under the appropriate quality of care or other relevant requirement. For example, if a resident develops a pressure injury because the facility’s nursing staff failed to provide care in accordance with professional standards of quality, the team should cite the deficiency at both F658 and F686 (Skin Integrity).

  • Do the services provided or arranged by the facility, as outlined in the comprehensive care plan, reflect accepted standards of practice?
  • Are the references for standards of practice, used by the facility, up to date, and accurate for the service being delivered?


To cite deficient practice at F658, the surveyor's investigation will generally show that the facility did one or more of the following:

  • Provided or arranged for services or care that did not adhere to accepted standards of quality;
  • Provided a service or care when the accepted standards of quality dictate that the service or care should not have been provided;
  • Failed to provide or arrange for services or care that accepted standards of quality dictate should have been provided.