January 2022

Plan of Care

It is incumbent upon all organizations to remain compliant with regulations. In order to ensure
compliance, we must first understand the regulations well. In this session, we will be discussing the
Medicare Conditions of Participation (CoP’s) related to the Home Health Plan of Care. We will be
focusing on the information contained in CoP Standard 484.60.

The objectives for this presentation are to:

 Understand the conditions of participation requirements for the home health plan of care
 Understand the components that are required in the plan of care
 Understand the relationship between the physician and the home health clinicians
 Understand the necessary communication related to plan of care

This particular standard is broken down into three components: the plan of care, the conformance
with physician orders, and the review and revision of the plan of care.

The standard starts off with language that states: Each patient must receive the home health
services that are written in an individualized plan of care that identifies patient-specific measurable
outcomes and goals, and which is established, periodically reviewed and signed by a doctor of
medicine, osteopathy or podiatry acting within the scope of his or her state license, certification or
registration. If a physician refers a patient under a plan of care that cannot be completed until after
an evaluation visit, the physician is consulted to approve additions or modifications to the original
plan. Here are some key phrases that we must be mindful of:
 Receive All Care Written
 Individualized
 Patient Specific Measurable Outcomes and Goals
 Established by Physician
 Periodically Reviewed by Physician
 Signed by Physician

It cannot be overstated that home health clinicians are acting only on the orders that have been
provided by the physician and that all orders must be included in the plan of care.

There are some key things to keep in mind as we comply with this condition. This includes the fact
that progress toward goals and outcomes must be clearly documented within the clinical record on
an ongoing basis. Surveyors will expect to see clearly outlined expected outcomes that are
specifically related to the unique needs and goals of the patient being reviewed.
 Canned documentation is unacceptable and likely will be cited.
 Every single order on the POC must be addressed in the clinical record.
 Parameters set by the physician within the POC must be recognized and should items fall
outside the parameters, those items must have documented notification to the physician.
 It is important to document the individual patient’s response to treatment and progress
toward goals established each visit.
 January 2022

 Records reviewed by the surveyors will expect individualized patient-specific goals based on
the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient
input.
 Goals for the patient, patient preferences and a clear and updated schedule of care to be
provided are an integral part of the patient care plan.

There are 16 items listed in the condition that must be included in the plan of care. These include:
1. All pertinent diagnoses
2. The patient’s mental, psychosocial and cognitive status
3. The services, supplies and equipment required
4. The frequency and duration of visits
5. The patient’s prognosis
6. Their rehabilitation potential
7. Their functional limitations
8. Their activities permitted (which would also infer any restrictions)
9. Their nutritional requirements
10. All medications and treatments being used
11. Safety measures
12. Risk for emergency department visits and associated interventions
13. Patient and caregiver education needed to facilitate a timely discharge (like all insurances,
Medicare does not want to be paying for care for any longer than necessary)
14. Patient specific interventions, education, measurable outcomes and goals
15. Advanced directives
16. Any additional items needed by either the physician or the home health organization

The condition also adds that all patient care orders, including verbal orders, must be recorded in the
plan of care.

That certainly is a lot to be mindful of and to include in the plan of care. Here are some thoughts on
the key points to remaining compliant:
 Make sure orders are specific.
o Lack of specificity in orders makes it difficult or impossible to determine if an order
is carried out as the physician intends.
 Keep your plan of care simple but specific.
 Clearly document how every single order has been followed. Do not skip or ignore orders on
the plan.
 List only orders that relate to the patient problems identified and goals established.
 The orders on the plan of care must indicate the type of services to be provided, including
the professional who will provide the services, the services that are to be provided and the
frequency of the services.
 January 2022

 The orders must be specific enough to establish that the physician was aware of the
procedure, technique, supplies to be used, the disciplines involved, frequency and duration,
the responsibility of the patient and/or caregiver and must include measurable goals.

The next section of the Condition (484.60 B, if you happen to be following along) deals with
conformance with physician orders. The first point made here is that the drugs, services and
treatments are administered only as ordered by a physician.

The next topic is related to vaccines, where the language states that Influenza and pneumococcal
vaccines may be administered per organization policy developed in consultation with a physician,
and after an assessment of the patient to rule out contraindications.

As hard as we may try, we are not likely to be able to identify all of the issues for the certification
period and have all orders in place on the original Plan of Care. In these situations, we will need to
obtain verbal orders from the physicians involved. It is explained that verbal orders must be
accepted only by personnel authorized to do so by applicable state laws and regulations and by the
organization's internal policies.

When services are provided on the basis of a physician’s verbal orders, in accordance with state law
and the organization’s policies, the licensed clinician must document the orders in the patient’s
clinical record, sign, date and time the orders.

Verbal orders must also be authenticated and dated by the physician in accordance with applicable
state laws and regulations, as well as the organization’s internal policies.

The final component of the condition deals with the review and revisions to the plan of care. As
each plan of care spans the 60-day certification period, the condition states that the individualized
plan of care must be reviewed and revised by the physician who is responsible for the home health
plan of care and the home health organization as frequently as the patient's condition or needs
require, but no less frequently than once every 60 days, beginning with the start of care date.

The reason to have the plan of care reviewed and updated more frequently than every 60-days
would be when there is a change in the patient’s condition. In this case, the home health
organization must promptly alert the relevant physician(s) to any changes in the patient's condition
or needs that suggest outcomes are not being achieved and/or the plan of care should be altered.

A revised plan of care must reflect current information from the patient's updated comprehensive
assessment, contain information concerning the patient’s progress toward the measurable
outcomes and goals identified by the home health organization and patient in the plan of care.

Any revision to the plan of care due to a change in patient health status must be communicated to
the patient, representative (if any), caregiver and all physicians issuing orders for the Home Health
Plan of Care.

The final portion of Condition 484.60 pertains to Discharge Communication, where any revisions
related to plans for the patient’s discharge must be communicated to the patient, representative,
 January 2022

caregiver, all physicians issuing orders for the home health plan of care and the patient’s primary
care practitioner or other health care professional who is responsible for providing care and services
to the patient after discharge from the home health organization.