What goes in a home health plan of care, and who signs it?
The short answer
Every home health patient has to get a written plan of care, and every visit has to follow it. A physician, nurse practitioner, clinical nurse specialist or physician assistant signs it, and nurses and therapists help build it. It covers things like diagnoses, medications, how often visits happen, safety and goals the patient helped set. It gets reviewed at least every 60 days. Until it's signed and dated, the agency can't send Medicare its claim for that 30-day period.
Every patient you see has a plan of care written for them, and you only give care that's been ordered. The plan is where those orders are kept.
Fine print
The rules say "each patient must receive an individualized written plan of care," and that drugs, services and treatments are given "only as ordered by a physician or allowed practitioner."
You may hear it called the 485
You may hear people call the plan "the 485." That was the number of a federal form, but the form itself is optional. An agency can use another document, as long as the physician signed and dated it and it has all the required data elements, in a place you can find it in the record.
Fine print
The form was titled Home Health Certification and Plan of Care. In 2003 CMS told its Medicare contractors the form "is optional." Agencies "may submit any document that is signed and dated by the physician that contains all of the required data elements in a readily identifiable location within the medical record and in accordance with the current rules governing the home health plan of care."
Who writes it and who signs it
A physician or an allowed practitioner signs the plan and keeps reviewing it. If you're the nurse or therapist on the case, you help write it, along with the patient, their representative (if they have one) and their caregivers.
If a referral comes in with too little to build a full plan, and it can't be finished until after an evaluation visit, the practitioner gets consulted to approve additions or changes to the original plan.
Fine print
An allowed practitioner is a nurse practitioner, clinical nurse specialist or physician assistant acting within state law, and they have counted since March 2020. The plan is "established, periodically reviewed, and signed by" a physician or allowed practitioner. The rule on skilled professionals lists "development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s)" among their responsibilities. Where a plan "cannot be completed until after an evaluation visit," the practitioner "is consulted to approve additions or modifications to the original plan."
What goes in it
Think of the plan as the whole picture of one patient: what's wrong, what care they're getting and how often, how to keep them safe, and the goals they're working toward. Those goals are meant to fit the patient in front of you, and the patient's own input is part of that.
Fine print
The rule lists sixteen items: (1) all pertinent diagnoses; (2) the patient's mental, psychosocial and cognitive status; (3) the types of services, supplies and equipment required; (4) the frequency and duration of visits; (5) prognosis; (6) rehabilitation potential; (7) functional limitations; (8) activities permitted; (9) nutritional requirements; (10) all medications and treatments; (11) safety measures to protect against injury; (12) the patient's risk of emergency department visits and hospital readmission, and what will be done about it; (13) patient and caregiver education and training, to help the patient be discharged on time; (14) patient-specific interventions and education, with measurable outcomes and goals; (15) information about any advance directives; (16) anything else the agency or the practitioner chooses to add. Medicare's payment rule adds one more: any remote patient monitoring or other telecommunications services. For item 14, the goals are those "identified by the HHA and the patient." CMS's guidance to surveyors says goals "must be individualized to the patient based on the patient's medical diagnosis, physician or allowed practitioner orders, comprehensive assessment and patient input."
Reading a visit order
Say you see "SN x 2-4/wk x 4 wk; 1-2/wk x 4 wk." That's skilled nursing two to four times a week for four weeks, then once or twice a week for four weeks. An order has to say which discipline is coming and how often. When an order gives a range, the top of the range counts as the frequency.
| In the order | What it means |
|---|---|
| SN | Skilled nursing. An order has to say which discipline is coming and how often |
| 2-4/wk x 4 wk | Two to four times a week for four weeks |
| 1-2/wk x 4 wk | Then once or twice a week for four weeks |
| A range, like 2-4 | The top of the range counts as the frequency |
Fine print
The Medicare manual shows that notation and says that when a range is ordered, "the upper limit of the range is considered the specific frequency."
As-needed visits and added visits
An order for "as needed" visits, written PRN, has to come with the signs and symptoms that would call for a visit, and a limit on how many of those visits can be made before another order is needed.
If you find the patient needs more visits or a new service, the order comes first. You can't add either until a physician or allowed practitioner has authorized it, in writing or orally.
There's one exception to "only as ordered." Flu and pneumococcal vaccines can be given under an agency policy, after the patient is assessed for contraindications.
Fine print
A PRN order "must be accompanied by a description of the beneficiary's medical signs and symptoms that would occasion the visit and a specific limit on the number of those visits to be made under the order before an additional physician or allowed practitioner order would have to be obtained." An increase in frequency or any new service "must be authorized by a physician or allowed practitioner by way of a written or oral order prior to the provision of the increased or additional services." The vaccine policy is one developed with a physician, physician assistant, nurse practitioner or clinical nurse specialist.
Verbal orders
Say a practitioner gives an order to staff, and it gets written down afterward. That's a verbal order. If you're the nurse or other qualified practitioner responsible for the ordered services, you write it in the patient's record and sign, date and time it. It also goes into the plan of care, and the practitioner who gave it signs and dates it afterward.
State law and your agency's policy decide who's allowed to take a verbal order, and how long the practitioner has to sign.
Fine print
Only staff authorized by state law and agency policy may accept a verbal order. The care-planning rule sets no number of days for the practitioner's signature. State rules do, and they differ. The ordering practitioner signs and dates it "in accordance with applicable state laws and regulations, as well as the HHA's internal policies." California's home health regulation allows 30 working days. Arizona's allows 30 calendar days. Texas leaves the time frame to each agency's policy.
When the patient's condition changes
When your patient's condition or needs change and it looks like the plan isn't getting results or should be altered, your agency has to promptly alert the relevant physician or allowed practitioner.
When the plan is revised because the patient's health changed, the patient, their caregiver and every practitioner issuing orders for the plan hear about the change.
Fine print
The rule says the agency "must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered." A revision "must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioners issuing orders for the HHA plan of care."
When a visit gets missed
When a visit gets missed, your agency should make every attempt to reschedule it, and let the responsible physician or allowed practitioner know if it can't.
Fine print
A missed visit is a departure from the plan. CMS's guidance to surveyors says the agency "should make every attempt to reschedule the missed visit," and if it cannot, "the responsible physician or allowed practitioner should be notified." The same guidance says the practitioner "should not be approached to reduce the frequency of services based solely on the availability of HHA staff."
The 60-day review
Plans don't sit still. They get reviewed and revised whenever the patient's condition or needs call for it, and at least every 60 days, counting from the start of care date. A revised plan has to reflect the updated assessment and the patient's progress toward their measurable outcomes and goals.
A plan can also lapse if a patient has no covered skilled visit in a 60-day period, unless the practitioner documents that the gap is appropriate to the treatment of the patient's illness or injury.
Fine print
When a lapse happens, Medicare treats the plan as terminated. The covered visits that count are skilled nursing, physical therapy, speech-language pathology and occupational therapy. The review rule says "as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date."
Why the signature matters to the claim
Until the practitioner has signed and dated the plan of care, your agency can't bill Medicare for that 30-day period. Verbal orders work the same way: the physician or allowed practitioner has to countersign and date them before the agency bills for the care.
Fine print
Medicare's payment rule says the plan must be signed and dated "before the claim for each" 30-day period "is submitted." Verbal orders "must also be countersigned and dated by the physician or allowed practitioner before the HHA bills for the care." In CMS's 2025 report, insufficient documentation was the largest single cause of improper payments in home health. The report covers claims from July 2023 through June 2024. The home health improper payment rate was 6.9%, about $1.07 billion, and insufficient documentation accounted for 49.4% of those dollars. The report does not break out unsigned plans of care.
What the patient gets in writing
The plan is written for clinicians, so your patient and their caregiver also get a plainer version in writing, including the clinical manager's contact details. The medication instructions have to use plain language, with no medical abbreviations. All of it is due no later than the next visit after the practitioner approves the plan of care.
Fine print
The agency must give the patient and caregiver written instructions with the visit schedule, the medication schedule, any treatments, any other instructions for the patient's care, and the "name and contact information of the HHA clinical manager." CMS's guidance says the medication administration instructions must be "written in plain language that does not use medical abbreviations." The timing is "no later than the next visit after the plan of care has been approved by the physician or allowed practitioner."