CMS SOM App. B, Tag G572

(1) Each patient must receive the home health services that are written in an

individualized plan of care that identifies patient-specific measurable outcomes and

goals, and which is established, periodically reviewed, and signed by a doctor of

medicine, osteopathy, or podiatry acting within the scope of his or her state license,

certification, or registration. If a physician or allowed practitioner refers a patient

under a plan of care that cannot be completed until after an evaluation visit, the

physician or allowed practitioner is consulted to approve additions or modifications

to the original plan.

Interpretive Guidelines §484.60(a)(1)

“Patient-specific measurable outcome” is a change in health status, functional status, or

knowledge, which occurs over time in response to a health care intervention that provides

end-result functional and physical health improvement/stabilization.

Patient-specific goals must be individualized to the patient based on the patient’s medical

diagnosis, physician or allowed practitioner orders, comprehensive assessment and

patient input. Progress/non-progress toward achieving the goals is evaluated through

measurable outcomes. The HHA must include goals for the patient, as well as patient

preferences and service schedules, as a part of the plan of care (See §484.60(a)(2) below).

“Periodically reviewed” means every 60 days or more frequently when indicated by

changes in the patient’s condition (see §484.60(c)(1)).

The patient’s physician or allowed practitioner orders for treatments and services are the

foundation of the plan of care. If the HHA misses a visit or a treatment or service as

required by the plan of care, the HHA should make every attempt to reschedule the

missed visit. If the visit cannot be rescheduled, the responsible physician or allowed

practitioner should be notified, and the HHA should document the potential clinical

impact of missed treatments or services. The HHA should advise and educate the patient

on the potential impacts of missed visits.

If the patient or the patient’s representative refuses care that could impact the patient’s

clinical wellbeing (such as dressing changes or essential medication) on more than one

occasion, then the HHA must attempt to identify the reason for the refusal. If the HHA is

unable to identify and address the reason for the refusal, then the HHA must

communicate with the patient’s responsible physician or allowed practitioner to discuss

how to proceed with patient care.

The physician or allowed practitioner should not be approached to reduce the frequency

of services based solely on the availability of HHA staff.

In instances where the HHA receives a general referral from a physician or allowed

practitioner that requests HHA services but does not provide the actual plan of care

components (i.e., treatments and observations) for the patient, the HHA will not be able

to create a comprehensive plan of care to include goals and services until a home visit is

done and sufficient information is obtained to communicate with and receive approval

from the physician or allowed practitioner.