Agencies struggle with plan of care

Improved communication is a key

Fifteen percent of Medicare home health agencies were cited for the same certification deficiency on three consecutive surveys, according to a report issued by the Office of the Inspector General in the Department of Health and Human Services. Most of the agencies included in this group were located in six states: California, Florida, Illinois, Iowa, Michigan, and Texas.

Compliance with plan-of-care requirements presented the biggest challenge, with almost half of the cited agencies not demonstrating that the patient's physician reviewed the written plan of care. Other plan of care-related citations included: not covering all diagnoses, not alerting physicians to changes in patient's condition, not following the plan of care to administer drugs and treatments, and not coordinating and supporting objectives outlined in the plan of care.

"Meeting the compliance standards related to the plan of care is a difficult area for all home health providers," says Trish Tulloch, RN, BSN, MSN, HCS-D, senior consultant for RBC Limited, a Staatsburg, NY-based home health consulting company. The most common reason for not following the plan of care is an inability to access the most up-to-date information, she explains. "About 40% of home health agencies are still using a manual, paper-based system," Tulloch says. "This means that updates to the plan of care might take several days as clinicians turn in notes, get approvals, or have data entered into the record," she explains.

If the plan of care can be updated at the home of the patient, during the visit, the next clinician to visit the patient has up-to-date information, Tulloch points out.

An automated system may assist the process of maintaining and communicating an updated plan of care, but it does not ensure that your agency will meet all compliance requirements, Tulloch points out. If your clinicians don't update the records on their laptops by downloading updates at the start of each day, or if they don't transmit updated information at the end of the day, the current information is not available to them or the next clinician to visit the patient, she explains. To ensure the use of the most updated plan of care, policies must be clear about procedures related to the plan of care, she says.

Clinicians at South Davis Home Health in Bountiful, UT, know expectations related to plan of care when they are hired, says Denise Cook, RN, quality assurance and quality improvement coordinator for the agency.

"Establishing a plan of care, charting to the plan of care, and following the plan of care are part of their job requirements and are included in their annual competencies," she explains.

Because her agency is not automated, paper forms are used for admissions and visit notes, says Cook. "Once the clinician completes the admission, a quality staff member reviews the forms to make sure that all diagnoses are included," she says. If there are any questions or if information that is needed to document the diagnosis is missing, the forms go back to the clinician for completion. During care, clinical coordinators review visit sheets submitted by nurses to make sure that the number of visits made to patients comply with their plans of care, says Cook. Coordinators also review clinical notes as they are completed to ensure that the services provided also match the plan of care, she adds.

"We also hold case conferences every two weeks to discuss patients and changes in their plans of care," says Cook. "We're a small agency, with about 40-50 patients per day, so we can talk about all of our patients in a one-hour meeting," she says. Attendance at the case conferences also is defined as an expectation in staff members' job descriptions, she adds.

Including the expectation that plans of care will be followed in a job description and job competency is important, but be sure you address a plan of care's importance in orientation and follow-up inservices, suggests Tulloch. In addition to presenting your agency's requirements, be sure to include the bigger picture, she says. "Point out that Medicare requires certain information, and emphasize that each clinical note should stand alone with the patient's homebound status and diagnoses clearly indicated on the form," she says.

Even if a hospice staff have addressed and is following a plan of care appropriately, a physician's signature must be on the plan, points out Tulloch. "It's important to establish a relationship with physicians' office staff to speed up the physician signature process," she says.

Although Cook is pleased with the way her agency handles plans of care, and they have no problems complying with Medicare requirements, she does point out that the process is constantly under review and improvement. "Making sure that we stay up to date and follow plans of care is always a work in progress," Cook says.

Need More Information?

For more information on complying with plan of care requirements, contact:

  • Denise Cook, RN, Quality Assurance and Quality Improvement Coordinator, South Davis Home Health, 401 S. 400 East, Bountiful, UT 84010. Telephone: (801) 298-8983. E-mail:
  • Trish Tulloch, RN, BSN, MSN, HCS-D, Senior Consultant, RBC Limited, 48 W. Pine Road, Staats-burg, NY 12580. Telephone: (845) 889-8128. Fax: (845) 889-4147. E-mail:
  • To access the full copy of "Deficiency history and recertification of Medicare home health agencies," go to