Home Health & Hospice

Insider’s Scoop | The role of the care plan in maintaining a compliant clinical record

Homecare Insider, November 2, 2015

Editor’s note: This week’s Insider’s Scoop was adapted from one of HCPro’s annual home health favorites, The 2015 Homecare Agency Reference Set, the most economical, efficient, and informative solution available to help home health agencies understand and address Medicare regulations and compliance. For just $230, you’ll receive the 2015 editions of The Home Health Guide to Medicare Service Delivery and The Home Health Conditions of Participation and Interpretive Guidelines. Each manual is packed with practical tips and expert advice and is indexed to easily find the information you need. For more information or to order, call customer service at 800-650-6787 or visit www.hcmarketplace.com

The written care plan is not simply busywork. It is essential in the organization, delivery, coordination, and communication of care. It helps demonstrate that the patient participated in the care planning process. It provides a succinct, written summary of the care the patient received to justify the delivery of skilled services. Written sections of the care plan reflect the process of skilled service delivery by accomplishing the following:
  • Identifying need/problem/nursing diagnosis that specifies the target of the skilled services
  • Identifying goals that demonstrate expected patient response or progress as a result of the skilled intervention
  • Showing, when implemented, the actual delivery of skilled services
  • Facilitating evaluation that measures the patient’s response and progress, as well as that reflects revision of the plan
The care plan also becomes the basis of outcome-oriented documentation in the visit notes.
The Conditions of Participation do not require an agency to develop or maintain a nursing care plan, as opposed to a medical plan of care. This does not preclude an agency from using nursing care plans if it believes that this strengthens patient care management, the organization and delivery of services, and the ability to evaluate patient outcomes.
CMS Publication 100-2, Chapter 7, §30.2.1, and the Conditions of Participation, §484.18(a), spell out the regulatory and survey requirements for the plan of care. The plan of care is for the attending physician only and is entirely prospective. The plan of care cannot show the care actually provided, evaluation of patient progress, or revision of the plan.
In an effort to reduce denials, many agencies have substantially increased their documentation on the plan of care, incorporating many elements once found on the care plan. Because of the potential duplication between the plan of care and the care plan, some agencies have gone so far as to eliminate the nursing care plan and put all that information on the plan of care. Agencies must carefully consider the conse­quences before eliminating discipline-specific care plans. The process of care delivery mandates a more detailed plan, one that goes beyond the requirements for the medical plan of care and incorporates patient response and ongoing evaluation. The care plan documents the plan for services in detail, incorporating nursing diagnoses and related concerns, and permits documentation of patient response and progress.
Through complete and accurate documentation on the plan of care and use of the care plan as the basis of care delivery, agencies can improve compliance, streamline care delivery, and minimize dupli­cation of documentation. This also means that providers must work together to ensure that interme­diaries and surveyors properly apply and interpret the homecare benefit and that all providers deliver and document care appropriately.

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