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Home Health Plan of Care

The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.

General Content in a Plan of Care

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.

The individualized plan of care must include the following:

    • All pertinent diagnoses;
    • The patient's mental, psychosocial, and cognitive status;
    • The types of services, supplies, and equipment required;
    • The frequency and duration of visits to be made;
    • Prognosis;
    • Rehabilitation potential;
    • Functional limitations;
    • Activities permitted;
    • Nutritional requirements;
    • All medications and treatments;
    • Safety measures to protect against injury;
    • A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
    • Patient and caregiver education and training to facilitate timely discharge;
    • Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;
    • Information related to any advanced directives; and
    • Any additional items the HHA or physician may choose to include.
    • All patient care orders, including verbal orders, must be recorded in the plan of care.

Plan of Care for Therapy Services

If the plan of care includes a course of treatment for therapy services:

    • Specific treatment strategies (e.g., specific modalities to be used, specific type of activities and exercises)
    • Areas of the body to be treated
    • Frequency of treatment with the anticipated number of visits per week
    • Duration
    • Patient instruction/home program
    • Caregiver training
    • Short term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment
    • Long term goals which are appropriate for the patient and the diagnosis and are stated in measurable terms with their expected date of accomplishment
    • Rehabilitation potential, which is a realistic evaluation of the patient's potential for rehabilitation/restoration using objective terminology
    • Signature and credentials of therapist performing the evaluation

Review and Revision of the Plan of Care

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 HHA 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 HHA must promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.

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

Revisions to the plan of care must be communicated as follows:

    • 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 HHA plan of care.
    • Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any).

Signature on the Plan of Care

The physician who signs the plan of care must be qualified to sign the physician certification.

Timeliness of Signature

If a physician signed plan of care is not available at the beginning of the episode, the HHA may submit a RAP for the initial percentage payment based on physician verbal orders OR a referral prescribing detailed orders for the services to be rendered that is signed and dated by the physician.

If the RAP submission is based on physician verbal orders, the verbal order must be recorded in the plan of care, include a description of the patient's condition and the services to be provided by the home health agency, include an attestation (relating to the physician's orders and the date received, and the plan of care is copied and immediately submitted to the physician. A billable visit must be rendered prior to the submission of a RAP.

Final Percentage Payment

The plan of care must be signed and dated by a physician as described who meets the certification and recertification and before the claim for each episode for services is submitted for the final percentage payment. Any changes in the plan of care must be signed and dated by a physician.

Verbal Orders

The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. The orders may be signed by the supervising registered nurse or qualified therapist after the services have been rendered, as long as HHA personnel who receive the oral orders notify that nurse or therapist before the service is rendered.

Oral orders must be countersigned and dated by the physician before the HHA bills for the care in the same way as the plan of care.

Facsimile Signatures

The plan of care or oral order may be transmitted by facsimile machine. The HHA is not required to have the original signature on file. However, the HHA is responsible for obtaining original signatures if an issue surfaces that would require verification of an original signature.

Alternative Signatures

HHAs that maintain patient records by computer rather than hard copy may use electronic signatures. However, all such entries must be appropriately authenticated and dated. Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. The HHA must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records in the event of a system breakdown.

Reference

42 CFR § 484.60

Medicare Benefit Manual Ch. 7 § 30.2

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