Care Plan Template for Non-Medical Home Care
A fill-in care plan for non-medical home care: ADL and IADL tasks, preferences, safety, schedule and review dates, plus Texas, Minnesota and Medicaid rules.
By Caregiver Scheduling Team ·
A non-medical home care plan lists what caregivers will do at each visit, how much help the client needs with each task, the client’s preferences and safety risks, the visit schedule, the charges, and when the plan will be reviewed. It is written at intake, signed by the client or representative, and updated when needs change. Most states that license personal care require one, and Medicaid requires a service plan before care starts.
What has to be in a care plan?
Services, frequency, location, start date, charges, who supervises, and signatures. Those are the elements Texas requires in a personal assistance agency’s individualized service plan, which must be “developed, agreed upon, and signed by the client or family and the agency” (26 TAC 558.404(f)). Minnesota adds fees, the staff who will provide each service, a monitoring schedule, and a contingency plan for missed visits (Minn. Stat. 144A.4791, subd. 9). The template covers both, plus the task detail, preferences and safety items caregivers need.
Care plan template
Copy this into your intake packet. Pair it with the client intake form and the printable ADL checklist.
Client: ______ DOB: ______ Address: ______ Emergency contact: ______ Physician: ______ Payer: ☐ Private pay ☐ LTC insurance ☐ Medicaid/waiver ☐ VA ☐ Other ______ Rate: $______/hour Minimum visit: ______ hours Start date: ______ Review date: ______ Supervisor: ______
| Day | Start | End | Hours |
|---|---|---|---|
Assistance levels: I = independent, S = standby or cueing, P = partial, F = full
| Personal care (ADLs) | Level | Frequency | Instructions |
|---|---|---|---|
| Bathing | |||
| Dressing | |||
| Grooming | |||
| Toileting and continence | |||
| Transfers | |||
| Walking and mobility | |||
| Eating |
| Household (IADLs) | Frequency | Instructions |
|---|---|---|
| Meal preparation | Diet: ______ | |
| Light housekeeping | ||
| Laundry | ||
| Medication reminders | Reminders only unless state rules allow more | |
| Errands and transportation | ||
| Companionship and activities |
Preferences: Language ______ Caregiver gender ______ Wake and sleep times ______ Pets ______ Likes and dislikes ______
Safety: ☐ Fall risk ☐ Walker, cane or wheelchair ☐ Memory loss ☐ Oxygen in home ☐ Allergies ______
If a visit cannot be covered: Office calls ______ by ______; backup caregiver ______.
Report to office immediately: falls, new pain, skin changes, confusion, refusing food or care, any emergency.
Client or representative ______ Date ______ Agency representative ______ Date ______
Which rules require a care plan?
Federal Medicaid rules, most state licensing rules, and every waiver program. Medicaid personal care must be authorized under a physician’s plan of treatment or a state-approved service plan (42 CFR 440.167). HCBS waiver clients get a person-centered service plan reviewed at least every 12 months (42 CFR 441.301(c)(3)). Your agency’s care plan has to match that authorized plan.
| Rule | Who it covers | What it requires |
|---|---|---|
| 42 CFR 440.167 | Medicaid personal care | Services authorized under a plan of treatment or state-approved service plan |
| 42 CFR 441.301(c) | HCBS waiver clients | Person-centered service plan, reviewed at least every 12 months |
| Texas 26 TAC 558.404(f) | Licensed personal assistance services | Signed individualized service plan with services, location, frequency, start date, charges and supervision |
| Minn. Stat. 144A.4791, subd. 9 | Licensed home care providers | Written service plan finalized within 14 days of the first visit, signed by both parties |
Your state may say “service plan,” “plan of care” or “care plan.” Find your rules in the licensing directory.
Who writes and signs the care plan?
The agency’s supervisor or care manager writes it with the client and family after an in-home visit, and the client or representative signs it. Texas requires the supervisor to be a licensed nurse or have two years of college, with substitutions for experience (26 TAC 558.404(g)). Minnesota requires both parties to sign. Even where no rule applies, a signed plan is your best defense when a family says a task was never agreed.
How often should a care plan be reviewed?
At least yearly, and after any change in condition. Medicaid waivers set the 12-month floor. Texas requires documentation that services were delivered according to the plan, so an out-of-date plan is a problem at every visit. Review after a hospital stay, a fall, a new diagnosis, or a change in who lives in the home, and make sure backup caregivers read the current version. See documenting ADLs and can caregivers give medication.
How Caregiver Scheduling handles this
The care plan lives on the client record, and caregivers see it in the app before each visit. The visit’s task list is on the phone, AI notes fill in the task checklist from what the caregiver says, and the client signs at check-out, which is the kind of proof of delivery Texas asks for. Preferred caregivers are assigned by default, and on Growth and up, authorized hours are checked so Medicaid visits stay inside the approved plan. $199/month for up to 10 caregivers or $299/month for up to 50, free for 30 days.
FAQ
Who writes the care plan? The agency’s supervisor or care manager at intake, with the client and family.
How often should a care plan be updated? At least every 12 months, and after any change in condition. Some states require more frequent reviews.
Is a care plan required for companion care? Not everywhere. It is required for Medicaid personal care and for licensed personal care in most states, and it protects you in disputes either way.
Can the care plan include medication help? Reminders, yes. Anything beyond reminders depends on your state’s delegation rules.
This article is general information, not legal advice. Check your state’s licensing rules.