HQAA’s standard for care plans:

PS 3: Plan of Care

The organization ensures all services provided are:

• Under a physician’s order
• Individualized to the patient receiving the care
• Consistent with other identified beneficiary needs, risks, and limitations of which the supplier is aware
• Reviewed periodically for revisions, updates, changes, and modification and the criteria for changes are defined
• Updates or revisions are collaborative with the physician, as needed.

This standard packs a lot of requirements and responsibilities into a couple dozen words! The company is held responsible for the care and treatment of the patient and expected to maintain a record that documents the care and treatment in great detail. Not just “We delivered oxygen to a new patient and set it up per the doctor’s order” but rather a thorough report of how the set up progressed, along with any specific and individualized problems or challenges encountered.

One size does not fit all in terms of plans of care. The plan of care should be about the patient and his or her tolerance of treatment, knowledge, reactions to teaching and reactions to the care or service. There are many different definitions for “plan of care” or “care plan”, but I like the one underlined in the paragraph above:

CARE PLAN = A record that thoroughly documents the care and treatment a patient receives

The plan of care starts with a physician order. The physician orders the equipment (or supplies, or therapy, or treatment) and it is the job of the DMEPOS provider to deliver that equipment/supplies/therapy. “Deliver” includes the physical act of taking the product or service to the patient, but it also includes teaching them how to use it.

“Individualized to the patient receiving the care” refers to how this documentation should be specifically about the individual patient. Documentation might include information such as:

• The goal of the treatment, therapy, or equipment usage.
• How the patient tolerated the therapy or using the equipment.
• Who else was taught to use the equipment or help with some therapy? List the caregivers and how they seemed to receive the education regarding the product or service.
• Notes about the home environment, depending on the type of equipment or service. Examples include notes about clutter or throw rugs for folks getting mobility aids or open flames (fireplaces, gas stoves, etc.) for folks getting oxygen equipment.
• Language barriers. Document any communication issues including patients or caregivers who don’t speak English or are deaf.
• Compliance with therapy or equipment. On subsequent visits, document issues when they come up. A very common example: when delivery technicians deliver tanks for an oxygen patient and find them using their equipment at a higher liter flow or not using it when they should.

Care plans should be reviewed periodically depending on the type of service. A care plan for a wheelchair or walker might be as simple as the delivery ticket, assuming education and home environmental issues are documented on that form. A care plan for a respiratory patient receiving PAP or oxygen would be more complex and include notes from subsequent visits whether they are visits to deliver tanks, maintain equipment, or provide clinical services. Rule of thumb: if there are any major changes that have an effect on the care and treatment, it should be documented. If an oxygen patient lives with a spouse or caregiver who does all the equipment maintenance, and that caregiver moves out or passes away, the care plan changes drastically.

“Updates and revisions are collaborative with the physician” refer to and remind us how important it is to include the physician in any changes or updates. The order/prescription may need to be adjusted or changed. At a minimum, the physician should be made aware of any changes that result in noncompliance with the prescribed therapy or care, or environmental issues that may affect the way care is given.

Organizations are expected to have a written policy that describes how the care plan is documented. During the pre-survey process, the organization is asked to submit that policy into the workroom, for review by the coaches. During the survey, this standard is assessed by the surveyor during patient record review and also during any home visits. If the surveyor sees anything problematic or unexpected during a home visit, they’ll most likely check the patient record to ensure that the organization has documented the issue or problem.  

Organizations providing clinical respiratory services or invasive ventilator services should also be mindful of heightened and increased requirements for plans of care. CRS 2: Physician Ordered Treatment Plan and IMV 3: Physician Orders Treatment Plan both address analogous requirements for more advanced patient care that involves hands on patient care, therapies, and patient services.

Finally, I think a helpful way to approach an organization’s care plans and care planning process is to remember that Care Plans are BOTH a “document” and an “idea”. Organizations with excellent, well thought out template documentation in a patient file can still end up deficient at PS 3. For instance, during a recent survey, I talked with a patient who said they only used their oxygen at night despite the continuous order. The organization’s staff was well aware that the patient did not follow the doctor’s order, but had not documented it anywhere in the care plan. The written care plan did not match what was actually happening. The actual care is important, but so is the documentation of that care.

Think of these care plans as the road maps you use to “find” the patient, check on them, and ensure the care is being delivered and consumed appropriately.