Plan Of Care Management

---
name: plan-of-care-management
description: "Manage the PT/rehab plan of care end to end — goals, frequency/duration, certification, and the recertification clock — so the POC stays signed and current, visits trace to goals, and a lapsing certification is re-booked before it invalidates visits."
---

# Plan-of-Care Management

The plan of care is a **living, signed instrument** with a certification clock. A lapsed cert can invalidate the visits under it.

## What a POC must carry

1. **Diagnosis + functional deficits** the therapy addresses.
2. **Measurable goals** (short- and long-term) with functional outcomes.
3. **Frequency × duration** (e.g. 2×/week × 6 weeks) — this is also the cadence operations must staff.
4. **Certification** — the required signature establishing the plan.
5. **A recertification clock** — the window after which the plan must be re-certified to keep billing valid.

## Certification vs recertification timing

- **Initial certification** establishes the plan within its required window.
- **Recertification** renews it before the certification period lapses or the plan changes materially.
- **Own the deadline here; the re-book is operations'** ([`../schedule-and-capacity-planning/SKILL.md`](../schedule-and-capacity-planning/SKILL.md)). Recertify *before* it lapses — a late recert is a denial waiting to happen.

## Verify-at-use

- **Certification windows, signature requirements, and recertification timing vary by payor and by CMS/Medicare rules and change** — confirm the current window against the specific payor/CMS source; cite + date, or mark `[unverified — training knowledge]`. No patient PII.

Traverse the certification-vs-recertification timing tree in [`../../knowledge/pt-clinic-decision-trees.md`](../../knowledge/pt-clinic-decision-trees.md); template at [`../../templates/plan-of-care.md`](../../templates/plan-of-care.md).