LONGITUDINAL COORDINATION
OF CARE WORK GROUP –
A Community Led Initiative
CARE PLAN TERMS &
PROPOSED DEFINITIONS
December 2012
Care Plan Terms & Proposed Definitions (DRAFT)
1
Table of Contents
Introduction ................................................................................................................................ 2
The Importance of Care Plan ..................................................................................................... 2
The Importance of Terms Used to Describe Care Plan .............................................................. 2
Policy Requirements and Care Plan ....................................................................................... 2
Terms, Structure, Components and Processes of Care Plan to Support Coordination of Care 3
Glossary of Terms – Care Plan Components/Elements .......................................................... 5
LCC Proposed Model of Care Plan:........................................................................................ 6
Emerging Terms ..................................................................................................................... 8
Appendix A: Meaningful Use Requirements for Care Plan ........................................................ 9
Stage 2 Meaningful Use Requirements for Care Plan ............................................................. 9
Future Stages of Meaningful Use ........................................................................................... 9
Appendix B: Physician Fee Schedule Requirements for Coordinating Care .............................11
Medicare Physician Fee Schedule Rule ................................................................................11
Appendix C: CMS Conditions of Participation Requirements for Care Plan ..............................12
Appendix D: CMS Interpretive Guidelines for Care Plan ..........................................................15
Appendix E: References ..........................................................................................................17
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Care Plan Terms & Proposed Definitions (DRAFT)
Introduction
The recent CMS Meaningful Use Stage 2 Final Rule and CY 2013 Medicare Physician Fee Schedule
(MPFS) Final Rule, introduced requirements to exchange care plan content with transitions of care and
referrals, and to enhance physician reimbursement for services related to Transitional Care Management.
The Standards and Interoperability (S&I) Framework Longitudinal Coordination of Care Workgroup (LCC
WG) August 2012 white paper, Meaningful Use Requirements For: Transitions of Care & Care Plans for
Medically Complex and/or Functionally Impaired Persons, identified the need for a more robust
description of care plan content to be exchanged as part of Meaningful Use requirements and in support
of medically complex and/or functionally impaired persons. Building on these documents, this Care Plan
Terms & Proposed Definitions, prepared by the S&I LCC WG, proposes standardized definitions for care
plan components framed from a broader perspective that begins to reflect the changing dynamics of
health care (e.g., ACOs, disease management, diverse settings of care). With this document, the LCC
WG solicits public feedback on descriptions of terms, structure, components and processes of care plan
to support coordination of care.
The Importance of Care Plan
Increasingly with the aging of the population, many will live for a substantial periods of time with serious
disability or illness. The complexity of acute illness superimposed on chronic disease and functional
impairment requires multiple providers of care in different sites. Such care requires a process to reconcile
the potentially conflicting interventions needed to address these issues, this process is care planning. The
product of this process, a Care Plan, is a prioritized list of health concerns (including medical diagnoses,
functional impairments, housing, transportation, nutrition, etc.) matched to the individual’s goals of care
and acceptable interventions. Most medical records reflect the past or the current status, but the care
plan anticipates the future and is more consistent with what the patient most cares about.
The Importance of Terms Used to Describe Care
Plan
The terms “care plan” and “plan of care” are not used consistently across health care settings and policy
requirements, are ambiguous, and appear to be used interchangeably. They lack the precision needed to
identify important concepts required in the management of medically complex and/or functionally impaired
individuals.
Policy Requirements and Care Plan
There are several policy provisions that require providers to establish “care plans”, “plans of
treatment” and “plans of care” including:
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Care Plan Terms & Proposed Definitions (DRAFT)

CMS Conditions of Participation, Conditions of Participation: Home Health Agencies.( §
484.18(a))
 CMS Requirements for States and Long Term Care Facilities (§ 483.20 (k))
 CMS Conditions of Participation for Hospitals (§ 482.61(c))
 JCAHO Ambulatory Accreditation Program (RC.02.01.01)
These concepts are not defined in these regulations but appear to be used synonymously and
sometimes interchangeably across and even within various regulatory requirements.
More recent policy requirements that have emerged which underscore both the importance of “care
plan” for medically complex /functionally impaired persons and the need to unambiguously define
these terms include:
Regulation
MU Stage 2 Final Rule
CY2013 Medicare Physician Fee
Schedule Final Rule
Request for Comment –
Meaningful Use Stage 3
Brief Description
Care plan content, if known, is required in the summary of
care for each transition of care or referral
Included payment provisions for Transitional Care
Management (TCM) and recognized the need for
communication and coordination across providers at
transitions of care
Proposes to build on Stage 2 care plan requirements for
MU Stage 3 and future stages
Table 1
Terms, Structure, Components and Processes of Care Plan to Support
Coordination of Care
The Relationship between Care Plans and Plans of Care
Each provider creates a plan of care with the individual that includes
instructions and a treatment plan often for a specific issue or for a limited
number of issues. Within this plan of care, conflicts that arise between
interventions proposed for the different issues are recognized and
reconciled by the provider and individual as part of the process of creating
this plan of care. The provider and individual continually modify this plan of
care as they assess its effectiveness and as other health concerns arise.
When there are multiple providers, as is often the case for individuals with
complex medical and functional needs, the individual has multiple plans of
care, one from each provider. When these plans of care become
numerous enough or begin to propose conflicting interventions, the
complexity of care requires a new process to reconcile these conflicting
plans of care. This process results in the creation of a Care Plan. , The
Care Plan reconciles conflicts among plans of care, identifies and fills gaps
in care and communicates the new parameters for interventions. The Care
Plan serves as a “master” or “blueprint” for coordination of all components
of care, attained through the negotiated, collaborative process with which
the individual and his/her interdisciplinary care team establish it.
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Care Plan Terms & Proposed Definitions (DRAFT)
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With the increased focus on communication and coordination of care across providers, settings and
time, the need for clear, unambiguous terms to express the structure, components and processes
needed to plan and coordinate care becomes critical. The LCC WG has prepared this Care Plan
Terms & Proposed Definitions document to catalog key terms and concepts, and serve as a vehicle
to gather input toward consensus on the semantics, structure, components and processes of this
foundational activity.
The LCC WG is proposing a set of data elements that we believe are required to create and
exchange a “Care Plan” (CP) for medically complex and functionally impaired individuals. We are
also proposing a set of definitions to help frame these data elements. These proposals comprise two
small steps towards the development of an unambiguous and shared view of the complex processes
involved in aligning the interventions required to meet the health concerns of these individuals. The
ultimate goal is to identify the information that is required for the exchange of a CP and standardize
the content, format and definitions of that information to support its interoperable exchange across all
relevant sites and to all involved parties.
The inability to create and exchange a CP is a growing problem. As our population ages and
accumulates chronic conditions, there is an increase in the number and types of interventions
required to address acute illness and to restore and maintain health and function. These
interventions involve more participants and more sites of care putting a premium on communication
and integration. As complexity increases so does the requirement to align interventions across
multiple sites and participants in order to avoid gaps in care, duplicate or conflicting interventions, and
deviation from the individual’s goals of care.
In parallel, healthcare payment models are evolving that put a premium on coordination of care
across multiple sites and providers. This is especially true for patients with complex medical and
functional needs who make up approximately 10% of patients and account for 70% of health care
expenditures. For these individuals, the CP provides the blueprint for aligning interventions to
improve quality and efficiency of care. Most individuals, the other 90%, do not require this level of
coordination or communication to receive efficient, high quality care. They receive most of their care
from one clinician or one team and their plan of care is effectively coordinated among a small group
of collaborating providers and/or provider and local POC team members.
Some individuals who have more than one significant health problem, have specific care teams
dedicated to their management. Currently, there are many different processes in place that create
effective integrated CPs for different subgroups of complex individuals (e.g., PACE, Hospice,
Disabled Children). Because these processes differ so widely (participants, governance, sequence,
critical elements), we have chosen to focus on the inputs required to create plans that are
independent of the population addressed or process used. We have defined a list of critical elements
that are required to create a CP.
We propose a standardized output for CP processes specifying the critical elements of a CP to
facilitate the development of the technical specifications required for its exchange. The output of the
care plan process becomes an essential part of the inputs for the next iteration.
In order to create a plan of care or a care plan, the LCC WG believes the following items are required:
 Crosswalk
o Health concerns and goals of care
o Plans of Care
 Goals of care
o Changes to goals of care
o Prioritized goals of care
 Health concerns specific to the providers’ plans of care
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Care Plan Terms & Proposed Definitions (DRAFT)








o Changes to health concerns
o Crosswalk of health concerns and goals
o Prioritized health concerns
Interventions
o Care instructions
o Changes to interventions
o Prioritized interventions
Issues identified that require attention in the next care plan or plan of care
Preferences (patient)
Observations/evaluations/assessments that indicate how effective the previous care plan or
plan of care was in addressing health concerns
Outcomes grouped by intervention
Situation and likely course
Team members
Timeframe for re-evaluation (e.g. events such as exacerbation of CHF)
Glossary of Terms – Care Plan Components/Elements
Term
Goals
Health Concern
Definition
CMS MU2 Final Rule, Page 54001, Column 2
The target outcome; target or measure to be achieved in the process of patient
care (an expected outcome).
LCC Proposed Definition:
A defined outcome or condition to be achieved in the process of patient care.
Includes 1) patient defined goals (e.g., prioritization of health concerns,
interventions, longevity, function, comfort) and 2) clinician specific goals to
achieve desired and agreed upon outcomes (include examples).
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Issues, current status and 'likely course' identified by the patient or team
members that require intervention(s) to achieve the patient's goals of care, any
issue of concern to the individual or team member.
how is this linked to HL7 health concerns definition?
Instructions
“Problems” and “diagnoses” will capture medical/surgical diagnosis but are
insufficient to capture the full array of issues that are important to individuals.
Health concerns include:

Medical/surgical diagnoses and severity (include examples)

Nursing/Allied Health/Behavioral Health issues

Patient reported health concerns

Behavioral/Cognition/Mood issues

Functional status, including ADL issues

Environmental factors (e.g. housing and transportation)

Social factors including availability of support and relationships

Financial issues (e.g. insurance, eligibility for disability)
CMS MU2 Final Rule, Page 54001, Column 1
By clinical instructions we mean care instructions for the patient that are specific
to the office visit. Although we recognize that these clinical instructions at times
may be identical to the instructions included as part of the care plan, we also
believe that care plans may include additional instructions that are meant to
address long-term or chronic care issues, whereas clinical instructions specific to
the office visit may be related to acute patient care issues. Therefore, we
maintain these as separate items in the list of required elements later.
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Care Plan Terms & Proposed Definitions (DRAFT)
Term
Definition
LCC Proposed Definition:
Information or directions to the patient and other providers including how to care
for their condition, what to do at home, when to call for help, any additional
appointments, testing, and changes to the medication list or medication
instructions, clinical guidelines and a summary of best practice.
Detailed list of actions required to achieve the patient's goals of care.
Interventions
Example:
A person sees their PCP for a cold and is instructed to rest, consume plenty of
fluids, take an expectorant twice daily, and return if symptoms do not abate in
within 7 days and call if the person develops serious symptoms such as high
fever.
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Outcomes
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Patient Preferences
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Problem
Team member
CMS MU2 Final Rule, Page 54001, Column 2
The focus of the care plan
LCC Proposed Definition:
An issue requiring intervention (subsumed under "Health Concerns")
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
LCC Proposed Model of Care Plan:
The LCC WG seeks public comment on the following model that recognizes that the complexity
of interventions increases with the number of health concerns. We believe that as the complexity of
the individual’s care increases there is a parallel increase required in the complexity of the processes
needed to insure that the components of that care are aligned with the patient’s goals and
preferences and not in conflict with each other. We believe that care planning can be enhanced by a
more granular care planning vocabulary that permits distinctions between the various levels of
coordination required. We propose the following concepts to clarify these levels of complexity:

Instructions: List of action steps provided to a team member or patient necessary to address
health concern.

Treatment Plan: Developed by a provider in collaboration with the individual to address an
individual health concern under the purview of a single provider.
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Care Plan Terms & Proposed Definitions (DRAFT)

Plan of Care: Developed in a provider setting and individually negotiated with the patient to
address health concern(s). A patient may have multiple plans of care originating with each of
several providers.

Care Plan: Assembled in close collaboration with the individual to take into account all the
existing barriers to care access as well as the individual’s goals, philosophies, and values that
may influence care. In this schema there is only one Care Plan. Its purpose is to coordinate two
or more Plans of Care, recognize difference and fill gaps. One variant of the Care Plan, the
Longitudinal Care Plan, is a forward looking document that establishes goals several years into
the future, and may address issues such as prevention and risk avoidance.
Figure 1
Term
Care Plan
Definition
CMS MU2 Final Rule Definition, Page 54001, Column 2
For purposes of the clinical summary, we define a care plan as the structure
used to define the management actions for the various conditions, problems, or
issues. A care plan must include at a minimum the following components:
problem (the focus of the care plan), goal (the target outcome) and any
instructions that the provider has given to the patient. A goal is a defined target
or measure to be achieved in the process of patient care (an expected outcome).
LCC Proposed Definition:
Longitudinal
Care Plan
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Plan of Care
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
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Care Plan Terms & Proposed Definitions (DRAFT)
Term
Treatment Plan
Definition
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Emerging Terms
The LCC WG seeks public comment on the following terms and definitions that are emerging in
discussions of care plan processes and technical specifications.
Term
Assessment
Decision Modifiers
Definition
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Governance
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Objectives
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Patient Status
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Plan owner
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Do we replace “plan owner” with the concept of
“management/stewardship”
Risk Factors
CMS MU2 Final Rule Definition: None
LCC Proposed Definition:
Status
Steward
The “Steward” assumes the responsibility for resolving conflicts among
different provider-driven Plans of Care by recognizing the need for and
then initiating the necessary provider to provider conversations to
resolve conflicts and oversee the process of negotiating alignment
Defer to phase two – focus on hierarchy of data.
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Care Plan Terms & Proposed Definitions (DRAFT)
Appendix A: Meaningful Use Requirements for
Care Plan
Stage 2 Meaningful Use Requirements for Care Plan
In support of the national health outcomes policy priority to improve care coordination, the MU Stage 2
Final Rule established objectives requiring the EP or EH/CAH who” transitions their patient to another
setting of care or provider of care, or refers their patient to another provider of care, provides a summary
care record for each transition of care or referral” and set measures requiring this information exchange to
occur for more than 50% of these transactions (page 54047). The rule also specifies data elements that,
if known, are to be included in the summary of care. New for MU Stage 2 is the inclusion of the following
care plan content among the data elements required in the summary of care:
 Care plan field, including goals and instructions.
 Care team including the primary care provider of record and any additional known care team
members beyond the referring or transitioning provider and the receiving provider (page
54016).
The MU Stage 2 Final Rule also provided the following definition of “care plan”:
For purposes of the clinical summary, we define a care plan as the structure used to define the
management actions for the various s conditions, problems, or issues. A care plan must include
at a minimum the following components: problem (the focus of the care plan), goal (the target
outcome) and any instructions that the provider has given to the patient. A goal is a defined target
or measure to be achieved in the process of patient care (an expected outcome) (page 54001).
The MU2 requirements do not adequately define the concept of care plan nor its component parts.
Future Stages of Meaningful Use
Proposals for future stages of Meaningful Use presented at the October 25, 2012 Health IT Policy
Committee (HITPC) Meaningful Use Work Group expand on the care plan requirements described above
and include: UPDATE THIS LANGUAGE TO RFC
MU Stage 3
EP/ EH / CAH Objective: EP/EH/CAH who transitions their patient to another setting of care or refers their
patient to another provider of care
Provide a summary of care record for each site transition or referral when transition or referral occurs with
available information
Must include the following four for transitions of site of care, and the first for referrals (with the others as
clinically relevant):
1. Concise narrative in support of care transitions (free text that captures current care synopsis and
expectations for transitions and / or referral)
2. Setting-specific goals
3. Instructions for care during transition and for 48 hours afterwards
4. Care team members, including primary care provider and caregiver name, role and contact info (using
DECAF)
Measure: The EP, eligible hospital, or CAH that site transitions or refers their patient to another setting of
care (including home) or provider of care provides a summary of care record for 65% of transitions of care
and referrals (and at least 30% electronically).
Certification Criteria: EHR is able to set aside a concise narrative section in the summary of care
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Care Plan Terms & Proposed Definitions (DRAFT)
document that allows the provider to prioritize clinically relevant information such as reason for transition
and/or referral.
Certification Criteria: Inclusion of data sets being defined by S&I Longitudinal Coordination of Care WG,
which and are expected to complete HL7 balloting for inclusion in the C-CDA by Summer 2013:
1. Consultation Request (Referral to a consultant or the ED)
2. Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home
Health Agency)
Undetermined Stage
EP/ EH / CAH Objective: EP/ EH/CAH who transitions their patient to another site of care or refers their
patient to another provider of care.
For each transition of site of care, provide the care plan information, including the following elements as
applicable:
•Medical diagnoses and stages
•Functional status, including ADLs
•Relevant social and financial information (free text)
•Relevant environmental factors impacting patient’s health (free text)
•Most likely course of illness or condition, in broad terms (free text)
•Cross-setting care team member list, including the primary contact from each active provider setting,
including primary care, relevant specialists, and caregiver
•The patient’s long-term goal(s) for care, including time frame (not specific to setting) and initial steps
toward meeting these goals
•Specific advance care plan (POLST) and the care setting in which it was executed
For each referral, provide a care plan if one exists
Measure: The EP, eligible hospital, or CAH that transitions or refers their patient to another site of care or
provider of care provides the electronic care plan information for 10% of transitions of care to receiving
provider and patient/caregiver.
Certification Criteria: Develop standards for a shared care plan, as being defined by S&I Longitudinal
Coordination of Care WG. Some of the data elements in the shared care plan overlap content represented
in the CDA. Adopt standards for the structured recording of other data elements, such as patient goals and
related interventions.
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Appendix B: Physician Fee Schedule Requirements
for Coordinating Care
Medicare Physician Fee Schedule Rule
The CY2013 Medicare Physician Fee Schedule Final Rule included payment provisions for Transitional
Care Management (TCM). It recognizes the need for communication and coordination across providers
at transitions of care. The TCM codes cover face-to-face and non-face-to-face post discharge services
such as communication with the patient, caregiver, home health agency or other community services;
education to support self-management, independent living, and activities of daily living; identification of
available community and health resources; obtaining and reviewing discharge information, reviewing
need for or follow-up on pending diagnostic tests and treatments; establishing referrals and arranging
community resources; etc.
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Care Plan Terms & Proposed Definitions (DRAFT)
Appendix C: CMS Conditions of Participation
Requirements for Care Plan
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
PART 484 - CONDITIONS OF PARTICIPATION: HOME HEALTH AGENCIES.
Subpart B - Administration.
§ 484.18 Condition of participation: Acceptance of patients, plan of care, and medical supervision.
Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and
social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of
care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.
(a) Standard: Plan of care. The plan of care developed in consultation with the agency staff covers all pertinent
diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis,
rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and
treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other
appropriate items. 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. Orders for
therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration.
The therapist and other agency personnel participate in developing the plan of care.
(b) Standard: Periodic review of plan of care. The total plan of care is reviewed by the attending physician and HHA
personnel as often as the severity of the patient's condition requires, but at least once every 62 days. Agency
professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care.
(c) Standard: Conformance with physician orders. Drugs and treatments are administered by agency staff only as
ordered by the physician. Verbal orders are put in writing and signed and dated with the date of receipt by the
registered nurse or qualified therapist (as defined in § 484.4 of this chapter) responsible for furnishing or supervising
the ordered services. Verbal orders are only accepted by personnel authorized to do so by applicable State and
Federal laws and regulations as well as by the HHA's internal policies.
[54 FR 33367, August 14, 1989, as amended at 56 FR 32974, July 18, 1991; 64 FR 3784, Jan. 25, 1999]
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
PART 483 - REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES.
Subpart B - Requirements for Long Term Care Facilities.
§ 483.20 Resident Assessment
(k) Comprehensive care plans.
(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and
timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the
comprehensive assessment. The care plan must describer the following—
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and
psychosocial well-being as required under § 483.25; and
(ii) Any services that would otherwise be required under § 483.25 but are not provided due to the resident's exercise
of rights under § 483.10, including the right to refuse treatment under § 483.10(b)(4).
(2) A comprehensive care plan must be—
(i) Developed within 7 days after completion of the comprehensive assessment;
(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility
for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent
practicable, the participation of the resident, the resident's family or the resident's legal representative; and
(iii) Periodically reviewed and revised by a team of qualified persons after each assessment.
(3) The services provided or arranged by the facility must—
(i) Meet professional standards of quality; and
(ii) Be provided by qualified persons in accordance with each resident's written plan of care.
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
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PART 482 - CONDITIONS OF PARTICIPATION FOR HOSPITALS.
Subpart E - Requirements for Specialty Hospitals.
§ 482.61 Condition of participation: Special medical record requirements for psychiatric hospitals.
(c) Standard: Treatment plan.
(1) Each patient must have an individual comprehensive treatment plan that must be based on an inventory of the
patient's strengths and disabilities. The written plan must include—
(i) A substantiated diagnosis;
(ii) Short-term and long-range goals;
(iii) The specific treatment modalities utilized;
(iv) The responsibilities of each member of the treatment team; and
(v) Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.
(2) The treatment received by the patient must be documented in such a way to assure that all active therapeutic
efforts are included.
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
PART 485 - CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS.
Subpart B - Conditions of Participation: Comprehensive Outpatient Rehabilitation Facilities.
§ 485.60 Condition of participation: Clinical records
(a) Standard: Content. . . .
(2) Current plan of treatment;
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
PART 485 - CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS.
Subpart H—Conditions of Participation for Clinics, Rehabilitation Agencies, and Public Health Agencies as
Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
§ 485.711 Condition of participation: Plan of care and physician involvement.
For each patient in need of outpatient physical therapy or speech pathology services there is a written plan of care
established and periodically reviewed by a physician, or by a physical therapist or speech pathologist respectively.
The organization has a physician available to furnish necessary medical care in case of emergency.
...
(b) Standard: Plan of care.
(1) For each patient there is a written plan of care established by the physician or by the physical therapist or speechlanguage pathologist who furnishes the services.
(2) The plan of care for physical therapy or speech pathology services indicates anticipated goals and specifies for
those services the—
(i) Type;
(ii) Amount;
(iii) Frequency; and
(iv) Duration.
(3) The plan of care and results of treatment are reviewed by the physician or by the individual who established the
plan at least as often as the patient's condition requires, and the indicated action is taken. (For Medicare patients, the
plan must be reviewed by a physician, nurse practitioner, clinical nurse specialist, or physician assistant at least every
30 days, in accordance with § 410.61(e) of this chapter.)
(4) Changes in the plan of care are noted in the clinical record. If the patient has an attending physician, the therapist
or speech-language pathologist who furnishes the services promptly notifies him or her of any change in the patient's
condition or in the plan of care.
Title 42 - Public Health. - .
SUBCHAPTER E - STANDARDS AND CERTIFICATION.
PART 486 - CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY SUPPLIERS
Subpart D—Conditions for Coverage: Outpatient Physical Therapy Services Furnished by Physical Therapists
in Independent Practice
§ 486.155 Condition for coverage: Plan of care
For each patient, a written plan of care is established and periodically reviewed by the individual who established it.
...
(b) Standard: Plan of care.
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(1) For each patient there is a written plan of care that is established by the physician or by the physical therapist who
furnishes the services.
(2) The plan indicates anticipated goals and specifies for physical therapy services the—
(i) Type;
(ii) Amount;
(iii) Frequency; and
(iv) Duration.
(3) The plan of care and results of treatment are reviewed by the physician or by the therapist at least as often as the
patient's condition requires, and the indicated action is taken.
(4) Changes in the plan of care are noted in the clinical record. If the patient has an attending physician, the therapist
who furnishes the services promptly notifies him or her of any change in the patient's condition or in the plan of care.
(For Medicare patients, the plan must be reviewed by a physician in accordance with § 410.61(e).)
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Appendix D: CMS Interpretive Guidelines for Care
Plan
State Operations Manual
Appendix B - Guidance to Surveyors: Home Health Agencies
§484.18(a) Standard: Plan of Care
G159
The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including
mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation
potential, functional limitations, activities permitted, nutritional requirements, medications and treatments,
any safety measures to protect against injury, instructions for timely discharge or referral, and any other
appropriate items.
G162
(Rev. 11, Issued: 08-12-05; Effective/Implementation: 08-12-05)
The therapist and other agency personnel participate in developing the plan of care.
Interpretive Guidelines §484.18(a)
A statutory change renamed the “plan of treatment” to “the plan of care.” These terms are synonymous.
Neither is to be confused with a nursing care plan.
The conditions do not require an HHA to either develop or maintain a nursing care plan as opposed to a
medical plan of care. This does not preclude an HHA from using nursing care plans if it believes that such
plans strengthen patient care management, the organization and delivery of services, and the ability to
evaluate patient outcomes.
...
Written HHA policies and procedures should specify that all clinical services are implemented only in
accordance with a plan of care established by a physician’s written orders.
...
The plan of care must be established and authorized in writing by the physician based on an evaluation of
the patient’s immediate and long term needs. The HHA staff, and if appropriate, other professional
personnel, shall have a substantial role in assessing patient needs, consulting with the physician, and
helping to develop the overall plan of care.
...
The patient has the right, and should be encouraged, to participate in the development of the plan of care
before care is started and when changes in the established plan of care are implemented.
"Care Plan"
Pg. 75 - "When corrections are made to an assessment already submitted to the state system, the HHA
must determine if there is an impact on the patient’s current care plan."
Pg. 91 - "Drugs and treatments ordered by the patient’s physician and not documented on the care plan
should be recorded in the clinical record."
State Operations Manual
Appendix PP - Guidance to Surveyors for Long Term Care Facilities
F279
§483.20(k) Comprehensive Care Plans
(1) The facility must develop a comprehensive care plan for each resident that includes measurable
objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that
are identified in the comprehensive assessment. The care plan must describe the following:
(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical,
mental, and psychosocial well-being as required under §483.25; and
(ii) Any services that would otherwise be required under §483.25 but are not provided due to the
resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).
S&I Longitudinal Coordination of Care WG
December 2012
Care Plan Terms & Proposed Definitions (DRAFT)
16
Interpretive Guidelines §483.20(k):
An interdisciplinary team, in conjunction with the resident, resident’s family, surrogate, or representative,
as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may
be expected to attain, based on the comprehensive assessment.
...
The care plan must reflect intermediate steps for each outcome objective if identification of those steps
will enhance the resident’s ability to meet his/her objectives. Facility staff will use these objectives to
monitor resident progress. Facilities may, for some residents, need to prioritize their care plan
interventions. This should be noted in the clinical record or on the plan or care.
F280
...
§483.20(k)(2) A comprehensive care plan must be-(i) Developed within 7 days after the completion of the comprehensive assessment;
(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with
responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s
needs, and, to the extent practicable, the participation of the resident, the resident’s family or the
resident’s legal representative; and
(iii) Periodically reviewed and revised by a team of qualified persons after each assessment.
Interpretive Guidelines §483.20(k)(2):
As used in this requirement, “Interdisciplinary” means that professional disciplines, as appropriate, will
work together to provide the greatest benefit to the resident. It does not mean that every goal must have
an interdisciplinary approach. The mechanics of how the interdisciplinary team meets its responsibilities in
developing an interdisciplinary care plan (e.g., a face-to-face meeting, teleconference, written
communication) is at the discretion of the facility.
...
"Plan of Care"
Pg. 34 - "The resident has the right to . . . Perform services for the facility, if he or she chooses, when--(i)
The facility has documented the need or desire for work in the plan of care;"
Pg. 60 - "Also determine if the plan of care was consistently implemented."
Pg. 84 - "This information should be noted in the assessment and identified in the plan of care."
Pg. 94 - "Observe during various shifts in order to determine if staff are consistently implementing those
portions of the comprehensive plan of care related to activities."
Pg. 99 - "If care plan concerns are noted, interview staff responsible for care planning regarding the
rationale for the current plan of care."
S&I Longitudinal Coordination of Care WG
December 2012
Care Plan Terms & Proposed Definitions (DRAFT)
17
Appendix E: References
Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2; Health
Information Technology: Standards, Implementation Specifications, and Certification Criteria for
Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for
Health Information Technology; Final Rules, 77 Fed. Reg. (2012) (to be codified at 42 C.F.R. Parts 412,
413, and 495)
Add CMS Online Manuals for CoP and Interpretive Guidelines
S&I Longitudinal Coordination of Care WG
December 2012