A Worked Home Care Plan Example (With Commentary)

A blank template is not the problem. Knowing what belongs in it is.

Most coordinators don't struggle to find a home care plan template — a search turns up dozens. What's harder to find is a filled-in one: an actual example of what a defensible, family-readable, licensing-ready plan looks like once someone has typed real information into every field. Blank templates hide the judgment calls. They don't show you how to phrase a goal, how to score a function, or how much detail an emergency section actually needs.

This article fills one in. The client below, "Mrs. Alvarez," is fictional — a composite built to be realistic without being identifiable, exactly the kind of client profile you'd see in any small private-pay agency's caseload. We'll walk through her plan section by section, explain why each entry looks the way it does, and flag the two scoring frameworks doing the real analytical work underneath it: the Katz Index of Independence in ADL and the Lawton-Brody IADL Scale. By the end, you'll have a concrete model to hold your own plans against — not just a shape to fill in, but a sense of what "good" looks like once it's done.

The client profile: what actually earns a line here

Mrs. Alvarez is 82, lives alone in a single-story home, and was referred to the agency after a fall in her kitchen three weeks earlier. Her daughter lives twenty minutes away and is the primary emergency contact. A basic profile section captures this in a few tight fields — not a biography, but enough context that anyone opening the file cold understands who they're caring for and why:

• Living situation: alone, single-story home, one flight of exterior stairs to the entry
• Primary diagnosis context: mild cognitive changes noted by her physician; no formal dementia diagnosis on file
• Referral reason: fall in kitchen, no fracture, three weeks prior to intake
• Support network: one adult daughter, local; no other regular in-person support

Notice what's absent: no diagnosis codes, no medication list with dosages, no insurance identifiers. A home care plan doesn't need to double as a medical chart — it needs to orient a caregiver or reviewer fast. If you're still deciding what belongs on this page at all, our guide to what a home care plan should include goes deeper on the boundary between "useful context" and "clinical overreach."

Scoring the ADLs: a worked Katz Index walkthrough

This is where a plan stops being descriptive and starts being measurable. The Katz Index of Independence in Activities of Daily Living was published in 1963 and covers six functions: bathing, dressing, toileting, transferring, continence, and feeding, according to the original Katz research as summarized by the Hartford Institute for Geriatric Nursing. Each function is scored independent or dependent, and the tool is reproducible for not-for-profit educational use with attribution to the Hartford Institute for Geriatric Nursing (HIGN), per HIGN's 2019 guidance.

Here's how Mrs. Alvarez's six functions were scored at intake:

Function Status Bathing Needs assistance (standby support for tub transfer) Dressing Independent Toileting Independent Transferring Needs assistance (post-fall caution) Continence Independent Feeding Independent

Four of six functions independent puts her in the moderate-impairment range under Katz scoring conventions, where a score of 6 indicates full function, 4 indicates moderate impairment, and 2 or below indicates severe impairment, per HIGN's 2019 scoring guidance. That single number — 4 — tells a reviewer more in one glance than a paragraph of narrative would, and it's timestamped, so a licensing inspector or a family member checking six weeks later can see exactly what changed and when.

This is also where a static Word document quietly fails an agency. A score typed into a table has no history — overwrite it next visit and the moderate-to-severe trajectory that mattered is gone. A plan built to snapshot each finalized version keeps that trail intact without anyone having to remember to save a new file name.

Scoring the IADLs: the Lawton-Brody worked example

Functional status alone doesn't capture whether someone can actually run a household. The Lawton-Brody IADL Scale, published in 1969, adds eight domains: telephone use, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for medications, and ability to handle finances, per the original Lawton-Brody study as reproduced by HIGN. Scoring runs 0 to 8, where 0 is fully dependent and 8 is fully independent, according to HIGN's summary of the instrument.

Mrs. Alvarez scored 5 of 8:

• Telephone — independent
• Shopping — needs assistance (no longer drives)
• Food preparation — independent, simple meals only
• Housekeeping — needs assistance
• Laundry — independent
• Transportation — dependent (no driving since the fall)
• Medication responsibility — needs assistance (see note below)
• Finances — independent

The IADL score is where a plan earns its keep with families: it's the section that explains, in one number plus eight lines of detail, why grocery delivery or a transportation arrangement is now part of the care goals rather than a vague "help around the house" note. If you're building this section from scratch, the care goals and outcomes worksheet walks through turning each IADL gap into a measurable goal rather than a to-do list.

Home safety and fall risk: what the assessment catches

Mrs. Alvarez's referral reason — a kitchen fall — makes the home safety section non-optional, and the numbers explain why every plan should treat it that way regardless of referral reason. More than one in four adults aged 65 and older, over 14 million people, fall each year, making falls the leading cause of injury for that age group, according to the CDC. One in ten falls causes an injury, and falling once roughly doubles the risk of falling again, per the same CDC data.

Her home safety assessment flagged three items: a loose kitchen rug (the likely cause of the original fall, now removed), no grab bar in the shower, and dim lighting on the exterior stairs. Each item gets a status — flagged, in progress, resolved — rather than sitting as an undated observation. That distinction matters again at review: "grab bar installed 4/12" is a fact a licensing reviewer can verify; "recommend grab bar" sitting unresolved for eight months is a liability if there's ever an incident on record.

Medication: organization, not clinical instruction

One line in Mrs. Alvarez's IADL scoring — "needs assistance" with medication responsibility — deserves its own note, because this is the section where plans most often overreach. Her plan lists a medication reminder schedule: what time of day each medication is typically taken, and a checkbox for the caregiver to confirm a reminder was given. It does not list dosages, does not track administration, and does not function as an electronic medication administration record. That's a deliberate boundary, not a missing feature — a private-pay home care plan is a reminder-and-organization tool for non-medical caregivers, not a clinical system, and it should never read like one. If a plan you're evaluating blurs that line, that's worth treating as a red flag rather than a bonus feature.

Care goals, the review cycle, and the finalize-and-share step

Everything above feeds into three or four concrete goals — reduce fall risk in the kitchen and bathroom, restore reliable transportation for shopping and appointments, and maintain medication reminder consistency — each with a target and a review date rather than an open-ended aspiration. Mrs. Alvarez's plan was set to review every 30 days for the first quarter, then every 90 days once her ADL and IADL scores held steady across two consecutive reviews.

When the plan was finalized, it was locked into a dated, immutable snapshot rather than left as an editable file that anyone could quietly overwrite. Her daughter received a read-only, token-authenticated link with an expiry date, so she could see the current plan without needing a login or a paper copy that goes stale the moment something changes. Because no client plan data is stored on the agency's servers by design in a system built this way, the daughter's access and the agency's documentation obligations stay architecturally separate from server-side patient data questions — worth understanding as how the system is built, though you should still confirm your own privacy obligations with your state licensing body or, in Canada, the Ontario IPC, rather than treating this as legal advice.

If you want a structured place to build a plan like this one rather than assembling it from scratch, our plan-of-care template for home care agencies and the ready-to-use Plan of Care / Service Plan Pack both start from the same section structure walked through here. And if you'd rather see the underlying shape of a full plan before scoring anyone, our home care plan template guide is the companion piece to this one.

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