CMS SOM App. B, Tag G574

(i) All pertinent diagnoses;

(ii) The patient’s mental, psychosocial, and cognitive status;

(iii) The types of services, supplies, and equipment required;

(iv) The frequency and duration of visits to be made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against injury;

(xii) A description of the patient’s risk for emergency department visits and

hospital re-admission, and all necessary interventions to address the

underlying risk factors.

(xiii) Patient and caregiver education and training to facilitate timely

discharge;

(xiv) Patient-specific interventions and education; measurable outcomes and

goals identified by the HHA and the patient;

(xv) Information related to any advanced directives; and

(xvi) Any additional items the HHA or physician or allowed practitioner may

choose to include.

Interpretive Guidelines §484.60(a)(2)

A detailed, individualized plan of care is critical to both the quality and safety of patient

care and therefore each of the required elements must be included.

• In general, pertinent diagnoses include, but are not limited to, the chief reason the

patient is receiving home care and the diagnosis most related to the current home

health plan of care.

Additionally, comorbid conditions that exist at the time of the

assessment, that are actively addressed in the patient’s Plan of Care, or that have

the potential to affect the patient’s responsiveness to treatment and rehabilitative

prognosis should be considered and documented.

• Mental status is generally screened by asking the patient questions on orientation

to time, place and person.

• Psychosocial status, as relevant to the patient’s plan of care, may include but is

not limited to, interpersonal relationships in the immediate family, financial

status, homemaker/household needs, vocational rehabilitation needs, family social

problems and transportation needs.

• In general, the plan of care should list the required supplies and equipment which

are non-routine and medically necessary for the patient’s care. Examples

include, but are not limited to, shower chairs, catheters, tube feeding supplies,

and ostomy bags.