Author: Lisa Meadows, MSW
Senior Manager, Survey Operations

Developing a plan of care that adheres to ACHC standards ensures that home care nursing services are delivered with efficiency, accountability, and compassion. By conducting thorough assessments, creating individualized care plans, continuously monitoring progress, and maintaining meticulous documentation, healthcare providers can enhance patient outcomes with consistent quality. Ultimately, a fully defined and implemented plan of care fosters  the collaborative and effective home care nursing that defines a patient-centered approach.

Assessment and Initial Planning

A comprehensive patient assessment is the foundation for an effective plan of care. ACHC standards emphasize a thorough evaluation of the patient’s medical history, current health status, functional limitations, psychosocial needs, and environmental factors. An initial assessment is conducted by a qualified registered nurse (RN) within 48 hours of referral and/or within 48 hours of the client’s/patient’s discharge to home. A comprehensive assessment must also be conducted by a qualified RN within five calendar days after the start of care.

Following the assessment(s), the RN collaborates with the patient, family members, and healthcare providers to establish specific, measurable, and achievable goals tailored to the patient’s condition and preferences.

Developing and Implementing the Plan of Care

The plan of care is individualized for each patient and detail the scope of services, interventions, and expected outcomes. According to ACHC standard, HC5-3F, the plan of care must include:

• Start of care date.
• Certification period.
• Client/patient demographics.
• Principle diagnoses and other pertinent diagnoses.
• Medications: dose/frequency/route.
• Orders for specific clinical services, treatments, procedures (with amount/frequency/duration specified).
• Equipment and supply needs.
• Caregiver needs.
• Functional limitations.
• Diet and nutritional needs.
• Safety measures.
• Measurable goals.

Services may require physician or allowed practitioner orders based on payor (e.g., Medicaid, Managed Care, and other third-party payors) and state. In these situations, the agency has a responsibility to obtain physician or allowed practitioner orders prior to initiation of the care/services and to notify the physician or allowed practitioner of any changes in the client’s/patient’s condition.

Verbal orders are documented and signed with the name and credentials of the personnel receiving the order and signed by the physician or allowed practitioner within the time frame established by the agency’s policies and procedures and/or state requirements.

Once the plan of care is established, home care staff is responsible for seamless implementation through effective communication, documentation, and adherence to best practices.

Ongoing Monitoring and Reassessment

The plan of care is a dynamic document that requires regular evaluation to ensure its continuing effectiveness. ACHC standard HC5-3N mandates that the POC is reviewed to determine progress, modify care strategies, and ensure continued appropriateness of services at least every 60 days.

Key aspects of reassessment include evaluating:

• Appropriateness of the care/service being provided.
• Effectiveness of care/service being provided based on client/patient outcomes and response to care/service.
• All care and services are provided as ordered.
• Effectiveness of how changes in the client’s/patient’s condition are communicated for needed revision of the plan of care.

Maintaining Compliance for Continuing Accreditation

In home care nursing, no less than in home health and hospice care, ACHC standards provide a framework for safe, effective, and individualized care in a home setting. The plan of care serves as a roadmap, guiding healthcare professionals in delivering services to meet patients’ needs.