How to write a POC (485) for Management and Evaluation of a patient care plan.

I need to write a POC for Management and Evaluation of a patient care plan. Please, please give me some suggestions on the wordings to use in locator 21. This Patient is an elderly, frail female with multiple caregivers who check in sporadicaly and share responsibilities, but do not follow any establised routine. Sometimes MD appointments are missed and sometimes insulin doses are missed because someone forgets to either check BS level or forgets to communicate to the next caregiver. What frequency do you guys suggest? is 1-2 x month sound OK?

Thank you so much in advnace.