Focus on a Plan of Care

A Plan of Care needs to be comprehensive and focused. The information in a Plan of Care must specify the roles of multiple professional skills and assist with creating a written template for all disciplines to provide quality care.

In developing a Plan of Care, it should reflect the observations of all professionals involved in the patient’s care. The information will be the combination of the OASIS assessment, physician orders, physician encounters, the evaluations of all therapy disciplines involved, as well as the input of the patient/caregivers. The Plan of Care acknowledges the clinical status of the patient and must present interventions to be implemented.

Reference: CMS IOM 100-02, Chapter 7, Section 30.2.1

The OASIS is a Medicare required document that all Home Health Agencies must complete. It is anticipated that patient needs identified by the OASIS assessment and various other resources would be included in the patient’s Plan of Care. The Conditions of Participation require that a clinical record containing pertinent findings in accordance with accepted professional standards be maintained for every patient receiving home health services. The medical record should reflect deficits identified during the assessment process along with physician orders to provide those essential therapies.

Reference: 42 CFR 484.48 - 484.55, Clinical Records

The Home Health registered nurse analyzes the assessment data to determine the diagnoses, and patient needs or issues.

• The responsibility of the home health nurse is to identify risks to the patient’s health and barriers to health which may include interpersonal, systemic, or environmental circumstances
• The home health nurse validates the diagnoses or issues with the patient, family, caregivers, and other healthcare providers

Reference: The American Nurses Association (2014) Home Health Nursing: Scope & Standards of Practice, 2nd Edition

Once the assessment has been completed, then the information needs to be integrated into a POC that is comprehensive and to achieve desired outcomes, the required comprehensive assessment would identify:

• The patient’s current health, psychosocial, functional, and cognitive status
• The patient’s strengths, goals, care preferences, including the patient’s progress toward achievement of the goals identified by the patient and measurable outcomes
• The patient’s continuing need for home care
• The patient’s medical, nursing, rehabilitative, social, and discharge planning needs
• A review of all medications
• The patient’s primary caregiver and/or the patient’s representative

Reference: Federal Register / Vol. 82, No. 9 / Friday, January 13, 2017 / Rules and Regulations; Medicare CoPs 4. Comprehensive Assessment of Patients (Proposed § 484.55)

The combination of the home health assessments and physician orders identify patient deficits and needs. When a health deficit is identified, then an effective intervention will need to be included in the Plan of Care to address the deficit. Specified disease related tasks become orders within the Plan of Care. The Plan of Care is then presented to the certifying physician for review. The certifying physician orders are incorporated in the Plan of Care and validated by a dated signature. All the processes that precede the creation of the Plan of Care culminate in a working document that directs care to be provided by skilled professionals for the patient. Ultimately, the Plan of Care becomes the focal point for the efforts that precede its creation and it directs the quality care that will follow for the home health patient.