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 a Care Plan .................................................................................................. 2
The Importance of Terms Used to Describe a Care Plan ........................................................... 3
Policy Requirements and the Ambiguous Use of Care Plans and Plans of Care .................... 3
Terms, Structure, and Components of Care Plan to Support Coordination of Care ................ 3
Appendix A: Meaningful Use Requirements for Care Plan ........................................................ 7
Stage 2 Meaningful Use Requirements for Care Plan ............................................................. 7
Future Stages of Meaningful Use ........................................................................................... 7
Appendix B: Physician Fee Schedule Requirements for Coordinating Care .............................10
Medicare Physician Fee Schedule Rule ................................................................................10
Appendix C: CMS Conditions of Participation Requirements for Care Plan ..............................11
Appendix D: CMS Interpretive Guidelines for Care Plan ..........................................................14
Appendix E: References ..........................................................................................................16
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Introduction
The recent Center for Medicare and Medicaid Services (CMS) Meaningful Use Stage 2 Final
Rule and calendar year (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. To further build on these guidelines, the S&I LCC WG has developed the following
document, Care Plan Terms & Proposed Definitions, to propose standardized definitions for
care plan components in support of the changing dynamics of health care (e.g., Affordable Care
Organizations (ACOs), disease management, diverse settings of care). This document
describes key terms, structure, and components a care plan to support coordination of care.
This document does not define the related processes of a care plan and/or roles and
responsibilities associated with those individuals that develop, manage or use a care plan.
The Importance of a Care Plan
Individuals of all ages are living longer with chronic illness and disability. As the number and
complexity of their health conditions increase over time and episodes of acute illness are
superimposed, the number of clinicians contributing to the care of these individuals increases as
well. It becomes significantly more difficult to align and coordinate care among a growing
number of providers in multiple sites.
Without a process to reconcile potentially conflicting plans created by multiple providers, it is
impossible to avoid unnecessary and potentially harmful interventions. Without such a process,
it is also difficult to shift the perspective of clinicians from the management of currently active
issues to consideration of future goals and expectations.
The Care Plan represents the synthesis and reconciliation of the multiple plans of care
produced by each provider to address specific health concerns. It serves as a blueprint shared
by all participants to guide the individual’s care. As such, it provides the structure required to
coordinate care across multiple sites, providers and episodes of care.
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Care Plan Terms & Proposed Definitions (DRAFT)
The Importance of Terms Used to Describe a Care
Plan
The terms “care plan” and “plan of care” appear to be used interchangeably within and among
policy statements. Neither term is used precisely enough to convey the difference between a
treatment plan for a specific condition, a plan of care proposed by an individual clinician to
address several conditions or a care plan that integrates multiple interventions proposed by
multiple providers for multiple conditions. The management of medically complex and/or
functionally impaired individuals requires all of these different types of plans. In order for these
individuals to receive the care they need, policy statements should reflect the precision required
to provide complex care.
Policy Requirements and the Ambiguous Use of Care Plans and Plans of
Care
There are several policy provisions that require providers to establish “care plans”, “plans of
treatment” and “plans of care” including:
 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 are listed in table 1. Within these regulations, the term ‘care plan’ and its
components are not defined in a clear and precise manner.
Table 1: Policy Requirements With Ambiguous Care Plan Terminology
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
Terms, Structure, and Components of Care Plan to Support Coordination
of Care
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 and components
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needed to plan and coordinate care becomes critical. The LCC WG has developed this Care
Plan Terms & Proposed Definitions document to catalog key terms and concepts so that it may
serve as a vehicle to gather input toward consensus on the semantics, structure, and
components of this foundational activity.
As part of it’s scope of work under the S&I Framework, the LCC WG has developed a set of
data elements that the WG believes are required to create and exchange a “Care Plan” (CP) for
medically complex and functionally impaired individuals1. To better normalize these data
elements across healthcare settings and scenarios, the WG is 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 that put a premium on coordination of care across
multiple sites and providers are evolving. 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 coordinated
among team members including one or more of a small group of collaborating providers and the
patient.
Individuals with more than one significant health problem may 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, etc.). Depending on the complexity of the patient and the numbers of clinical
disciplines involved and the patient’s preferences, it may be necessary to reconcile and align
care plans across disciplines.
The following table lists LCC WG proposed definitions for key ‘care plan’ terms and
components. For comparison, applicable terminologies from the Meaningful Use (MU) stage 2
rule are provided.
1
The S&I LTPAC Sub-workgroup has identified over 480 unique data elements for LTPAC information
exchange. The final list is available at:
http://wiki.siframework.org/file/view/IMPACT%20Transfer%20of%20Care%20Dataset%2010-20-12%20%20For%20Distribution.xls/375236566/IMPACT%20Transfer%20of%20Care%20Dataset%2010-20-12%20%20For%20Distribution.xls
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Further information on the stage 2 requirements for care plan and future stages for MU are
provided in Appendix A.
Appendix B lists the Physician Fee Schedule requirements for coordinating care, Appendix C
outlines the CMS conditions of participation requirements for Care Plan and Appendix D
provides the CMS Interpretive Guidelines for Care Plan.
Table 2: LCC WG Proposed Definitions for Care Plan Terms/ Components
Term/Component
MU2
LCC Proposed
Definition
CARE PLAN
Not defined
The S&I LCC believes that the exchange of care plans is
important to support collaboration across care settings and
providers, and allows for and can encourage team based care.
The S&I LCC believes that a “care plan” considers the whole
person and focuses on a number of health concerns to achieve
high level goals related to healthy living.
In contrast, some clinicians use the concept of “plan of care” to
focus on discrete problems, the specific interventions to
address the problem, and achieve a certain goal related to the
problem.
Term/Component
MU2
LCC Proposed
Definition
The S&I LCC WG believes that both the Care Plan and Plan of
Care share the universal components: health concern, goals,
instructions, interventions, and team member.
HEALTH CONCERN
 Health concern is not defined.
 “Problem” is defined as “The focus of the care plan”
Health concerns reflect the 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.
“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
 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)
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Term/Component
MU2
LCC Proposed
Definition
Term/Component
MU2
LCC Proposed
Definition
Term/Component
MU2
LCC Proposed
Definition
Term/Component
MU2
LCC Proposed
Definition
Term/Component
MU2
LCC Proposed
Definition
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GOALS
The target outcome; target or measure to be achieved in the
process of patient care (an expected outcome).
A defined outcome or condition to be achieved in the process
of patient care. Includes patient defined goals (e.g.,
prioritization of health concerns, interventions, longevity,
function, comfort) and clinician specific goals to achieve
desired and agreed upon outcomes.
INSTRUCTIONS
“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.”
Information or directions to the patient and other providers
including how to care for the individual’s 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
Not defined
Actions taken to maximize the prospects of achieving the
patient's or providers' goals of care, including the removal of
barriers to success.
Instructions are a subset of interventions.
OUTCOMES
Target outcome; target or measure to be achieved in the
process of patient care (an expected outcome).
Status, at one or more points in time in the future, related to
established care plan goals.
TEAM MEMBER
Care team includes the primary care provider of record and any
additional known care team members beyond the referring or
transitioning provider and the receiving provider.
Parties who manage and/or provide care or service as
specified and agreed to in the care plan, including: clinicians,
other paid and informal caregivers, and the patient.
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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 in the November 2012 Health IT
Policy Committee (HITPC) request for comments (RFC) regarding the Stage 3 definition of
meaningful use of EHRs, expand on the care plan requirements described above and include:
ID# SGRP 303 (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
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Care Plan Terms & Proposed Definitions (DRAFT)
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 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)
Questions/Comments:
*What would be an appropriate increase in the electronic threshold based upon evidence and
experience?
ID# SGRP 304 (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
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Care Plan Terms & Proposed Definitions (DRAFT)
data elements, such as patient goals and related interventions.
Questions/Comments:
1. How might we advance the concept of an electronic shared care planning and collaboration
tool that crosses care settings and providers, allows for and encourages team based care,
and includes the patient and their non-professional caregivers?
 Interested in experience to date and the lessons learned.

Think through these priority use cases:
o Patient going home from an acute care hospital admission
o Patient in nursing home going to ED for emergency assessment and returning
to nursing home
o Patient seeing multiple ambulatory specialists needing care coordination with
primary care
o Patient going home from either hospital and / or nursing some and receiving
home health services
2. What are the most essential data elements to ensuring safe, effective care transitions and
ongoing care management? How might sharing key data elements actually improve the
communication? Consider health concerns, patient goals, expected outcomes,
interventions, including advance orders, and care team members. What data strategy and
terminology are required such that the data populated by venue specific EHRs can be
exchanged. How might existing terminologies be reconciled?
3. What are the requirements (legal, workflow, other considerations) for patients and their
identified team to participate in a shared care plan? Is it useful to consider role-based
access as a technical method of implementing who will have access to and be able to
contribute to the care plan? How will such access be managed?
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Appendix B: Physician Fee Schedule Requirements
for Coordinating Care
Medicare Physician Fee Schedule Rule
The calendar year (CY) 2013 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).
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(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.
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
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therapist or speech-language 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.
(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
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(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).
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."
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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
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