Free care plan template for non-medical home care

Fill it in at the in-home assessment, have the client or representative sign it, and give the caregiver a copy before the first visit.

Read the guide

Agency:

Plan of care

Client DOB Address Emergency contact Physician

Payer: Private payLTC insuranceMedicaid/waiverVAOther

Rate $/hour Minimum visit (hours) Start date Review date Supervisor

Schedule

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 riskWalker, cane or wheelchairMemory lossOxygen in homeAllergies:

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

How often should a care plan be reviewed?

At least as often as your state or payer requires, and whenever the client's condition changes. Medicaid HCBS waiver service plans must be reviewed at least every 12 months under 42 CFR 441.301(c); many state licensing rules set shorter intervals. Reported changes on the ADL checklist are the usual trigger for an early review.

How Caregiver Scheduling handles this

Each visit in a caregiver's day shows the client's times, address and care needs in the app, so the care plan travels with the schedule instead of living in a binder. See the caregiver app.

These free tools are made by the team behind Caregiver Scheduling, caregiver scheduling software for home care agencies.

Simple pricing

From $199 /month

Up to 10 caregivers on Starter, 50 on Growth.

More than 50 caregivers? We'll put together a custom Scale plan for your agency.

Book my demo See pricing