what is plan of care

Plan of Care Requirements
For any delivered home health service to be payable, HRSA requires home health providers to develop and implement an individualized Plan of Care (POC) for the client.
Note: Home health providers are required to comply with audits and/or site visits to
ensure quality of care and compliance with state rule. All documentation in the
client record, including the signed Plan of Care, must be made available to HRSA
upon request.

About the Plan of Care
The POC must:
• Be documented in writing and be located in the client’s home health medical record;
• Be developed, supervised, and signed by a licensed registered nurse or licensed
therapist;
• Reflect the physician’s orders and client’s current health status;
• Contain specific goals and treatment plans;
• Be reviewed and revised by the licensed registered nurse or licensed therapist and the
client’s physician at least every 60 calendar days;
• Signed by the physician within 45 days of the verbal order;
• Returned to the home health agency’s file; and
• Be available to department staff or its designated contractor(s) on request.

What must be included in the Plan of Care?
The provider must include in the POC all of the following:
• The client’s name and date of birth;
• The start of care;
• The date(s) of service;
• The primary diagnosis (the diagnosis that is most related to the reason the client
qualifies for home health services) and is the reason for the visit frequency;
• All secondary medical diagnosis including date(s) of onset (O) or exacerbation (E);
• The prognosis;
• The type(s) of equipment required;

• A description of each planned service and goals related to the services provided;
• Specific procedures and modalities;
• A description of the client’s mental status;
• A description of the client’s rehabilitation potential;
• A list of permitted activities;
• A list of safety measures taken on behalf of the client; and
• A list of medications which indicates:
Any new (N) prescription; and
Which medications are changed (C) for dosage or route of administration.

Important Information to Send with the Plan of Care if not Already
Included
The provider must include in, or attach to the POC:
• Client’s address including name of the residential care facility where the client is residing
(if applicable).
• A description of the client’s functional limits and the effects;
• Documentation that justifies why the medical services should be provided in the client’s
residence instead of a physician’s office, clinic, or other outpatient setting;
• Significant clinical findings;
• Dates of recent hospitalization;
• Notification to the DSHS case manager of admittance;
• A discharge plan, including notification to the DSHS case manager of the planned
discharge date and client disposition at time of discharge; and
• A short summary of what is happening with the client or what has happened since last
review.