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Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2025 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
06 Frequent Deficiencies In Home Care Agencies
14 Frequent Deficiencies
in Home Health Agencies
24 Frequent Deficiencies in Hospice Agencies
38 Frequent Deficiencies in Home Infusion Therapy
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
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SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your agency. Whether you are new or have years of experience with us, I am confident that you have already felt first- hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in— and passion for—the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource, demonstrating how ACHC program teams work to help you develop individual expertise within your agency, while recognizing that your staff may have varying levels of experience and current knowledge. The standards listed are the most frequently noted as non-compliant on recent surveys and the compliance tips provided are divided into categories to make them useful for individuals across a range of roles and expertise. “Accreditation Nerd Newbies” are just that: individuals new to the process of compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards. Even a "simple" standard may include multiple
elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their agency's capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand the goal. Partnership you can rely on Once an agency is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC's staff of Accreditation Nerds—account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
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FROM THE PROGRAM DIRECTOR
Hospice Results Like findings for home health agencies, hospice deficiencies are generally consistent and clustered in section 5: Provision of Care and Record Management . This year, seven standards were cited on more than 20% of the surveys performed and all but one came from this section. Year over year, HSP5-4A is the most frequently cited. It addresses the requirement for an individualized, written plan of care designed to manage the scope of issues identified on the initial, comprehensive, and updated comprehensive assessments. The plan is interdisciplinary, and developed collaboratively with the care team, the attending physician, and the patient or representative. It requires a level of detail adequate to direct all care and services. It is reviewed regularly for alignment with the medication profile, care orders, and therapies and services delivered. It is closely related to other standards identified in this report, which can create a cascade of deficiencies. ACHC focuses on providing education needed to bridge gaps in compliance. Webinars and training support compliance throughout the accreditation cycle and the onsite survey is an opportunity to ask clarifying questions to unblock full understanding of the standards. Home Infusion Therapy Results This year, we focus on standards that were cited for non-compliance on at least 20% of the surveys performed. Three years ago, when this cohort of providers was last surveyed, three standards were noted as deficient on more than 20% of the surveys. This year, three standards again reached that frequency, but a new standard emerged as the most challenging. HIT5-1A was cited on 43% of surveys. The standard requires that the organization's policy for client/ patient records include specific items. Findings did not identify missing or inadequate policies.
A survey with no findings—no identification of non-compliance—is exceedingly rare and that knowledge can be daunting. The important takeaway when exploring deficiency data is growth and improvement. This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for four individual ACHC accreditation programs: Home Care, Home Health, Hospice, and Home Infusion Therapy. This year’s data span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
Instead, ACHC Surveyors noted that policies were not adequately implemented. Documentation did not include the detail needed to support excellent patient care. There's much better news for HIT5-3C which was a finding on 71% of surveys in 2022 and for only 26% this year. This requirement for the plan of care includes specific data points but previous deficiencies focused on the absence of a physician signature. This year, very few plans of care lacked evidence of physician oversight but some were missing other required elements. Standard HIT5-8B was noted on 21% of surveys. The standard which focuses on regular review of patient medications by a licensed, skilled professional, improved for this cohort of providers by 12.5% over 2022 results. Summary The common theme across these four programs is the need for improvement in documentation. A complete and accurate written record tells the story of each patient's care. This is essential to continuity and coordination across handoffs. Many of these rely on the written record in home based care where team members may have fewer opportunities to interact face to face. Promote staff training and frequent audits of patient records for completeness and consistency. These are avoidable deficiencies! Reach out to ACHC for additional guidance If you find persistent sticking points. We're here to help you do better — for your patients and your agency!
Home Care Results Six standards were cited as non-compliant on more than 15% of the surveys covered by this report. HC5- 3K remains the most consistently challenging for agencies. It was cited on 40% of surveys, a decline in performance from last year, but an improvement for the organizations in this triennial cohort that were previously surveyed in 2022. Three years ago, it was cited on 52% of surveys. Each of the six home care standards on the pages that follow requires documentation of actions and effective team communication. Standard HC2-4B concerns the client’s right to file a complaint, Standard HC4-2C requires proper TB testing and evidence of an annual risk assessment; and the four standards from Section 5: Provision of Care and Record Management , all refer to information that should be present in the client/ patient record. Agencies that implement effective training for documentation practices will be in good stead for their next accreditation survey. Keep it concise but explicit and complete, record what and how required services are to be delivered.
Home Health Results In home health agencies, frequent deficiencies tend to be consistent year over year. This is because many of the standards, especially those in Section 5: Provision of Care and Record Management , have a large number of individual elements that require specific evidence of compliance. For an individual agency, the scope and nature of the deficiencies on the Summary of Findings gives context for the most common deficiencies. For example, are your agency’s deficiencies consistent across a majority of patient or personnel records? This would indicate a systemic problem that could be the focus of a performance improvement project. Is the non-compliance related to a particular discipline or even to patients assigned to an individual clinician? This would indicate a need for focused training on documentation requirements. Finally, are documentation errors isolated? This can be corrected with additional oversight and spot audits. From a high-level perspective, the good news is that a comparison of this year’s results with those from 2022 when this same cohort of agencies was last surveyed shows consistent improvement. The aggregated average frequency of the top eight standards in 2022 was 41%. This year, that average dropped to 32%. Every individual standard noted in this year’s report showed improvement from three years ago with the exception of HH5-1A which held steady as a deficiency finding for 22% of the organizations surveyed.
Susan Mills Senior Program Director
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HOME CARE
SECTION 2: PROGRAM/SERVICE OPERATIONS HC2-4B Frequency of the citation: 16%
Overview of the requirement: At the time of admission, the home care agency must inform each client/patient about how to contact its office, ACHC, and its state regulatory hotline with a grievance or complaint. Comment on deficiencies: C ompliance is assessed through review of policies and procedures, patient records, and new client/ patient packets. Most deficiencies noted one or more missing element of d ocumentation. Examples of ACHC Surveyor findings: ■ Agency policy requires that clients sign a form confirming receipt of specific items related to admission. The list includes information regarding grievances. None of the records reviewed included patient signatures on this form. ■ There was no evidence that the agency advised clients/patients in writing of the appropriate state regulatory body’s hotline telephone number(s), hours of operations and the purpose of the hotline. No evidence was found that the patient was provided with contact information for ACHC. ■ The state defines specific language that must be provided to clients on or before the first day services about how to report complaints; abusive, neglectful, or exploitative practices; and Medicaid fraud. The agency had no evidence of a written policy for providing this information. ■ The agency’s Patient Handbook identified a previous Administrator as the current agency contact. ■ The Patient Rights Form states “there is a process to voice grievances about service, treatment, or discrimination without fear of reprisal by calling [the agency] at the following phone number.” There is no phone number listed and there is no contact person identified with whom to place the complaint.
HOME CARE SERVICES AND DISTINCTIONS Services Home Care Aide Home Care Companion Home Care Nursing Home Care Occupational Therapy
Distinctions Palliative Care Telehealth
Home Care Physical Therapy Home Care Social Services Home Care Speech Therapy
FREQUENT DEFICIENCIES FROM HOME CARE SURVEYS 60%
50%
40%
30%
20%
10%
0%
HC2-4B
HC4-2C
HC5-3G
HC5-3K
HC5-3L
HC5-7B
Provision of Care and Record Management
Program/Services Operations
Human Resources Management
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Compliance tips for:
Compliance tips for:
■ This standard focuses on TB infection prevention and control by confirming baseline testing and an exposure screening of direct care personnel prior to initial client/patient contact. ■ A second required element is an annual organizational risk assessment that informs the need, type, and frequency of assessment and testing for individual agency staff. ■ Immediately inform your agency of a suspected or documented exposure. This may trigger additional testing for staff. ■ (HR staff) Check new hire personnel files for inclusion of baseline TB testing documentation and individual risk assessment prior to initial patient contact. ■ (Infection preventionists) Conduct and document the annual risk assessment and record the intended cadence of staff assessment/testing. ■ Offer to research TB risk assessment tools and customize a resource for your agency to use.
■ The agency must provide contact information for the purpose of reporting grievances/complaints. Contact information must be provided to the client/ patient no later than the start of service delivery for: ٝ The agency. ٝ The state complaint hotline. ٝ ACHC. ■ There are three locations for evidence of compliance: ٝ Agency policy and procedure. ٝ Admission packets. ٝ Client records. ■ Update policies and procedures, and admission packet forms each time there is a change in the agency administrator. ■ Check new admissions records monthly for inclusion of required documentation. ■ Lead onboarding and in-service training related to required client/patient record documentation.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Nerd Trailblazers (prepare the path for others)
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HC5-3G Frequency of the citation: 19% Overview of the requirement: Home care aide services are identified from the written plan of care for each client/patient. Note: This standard applies to Home Care Aide (HCA) Services only. Comment on deficiencies: Compliance is assessed through client/patient records. Most deficiencies indicated that aide-level elements from the plan of care were not clearly identified for that role, or lacked adequate detail, e.g., frequency or duration. Examples of ACHC Surveyor findings: ■ The aide plan of care listed mobility/transfer with no additional information. ■ Client’s skilled nursing start of care assessment identified safety risks for fall and bleeding, and the use of universal precautions. The aide assignments include no evidence of these concerns. ■ Aide services did not include frequency or duration of care.
SECTION 4: HUMAN RESOURCE MANAGEMENT HC4-2C Frequency of the citation: 16%
Overview of the requirement: Upon hire, direct care personnel must have a baseline tuberculosis (TB) skin or blood test and an individual TB risk assessment and symptom evaluation prior to initial patient contact. Comment on deficiencies: Compliance is assessed through review of policies and procedures and personnel files. Deficiencies noted that some personnel files included evidence of a baseline TB test while others did not. Also noted was a lack of an annual risk assessment to inform the need and frequency of testing for direct care personnel. Examples of ACHC Surveyor findings: ■ Personnel records were inconsistent regarding documentation of a baseline TB test. ■ Aides had no initial TB testing requirement. ■ There was no record of that an annual TB risk assessment was completed.
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■ The plan of care orders mouth/oral/denture care every Saturday and Sunday. This activity is not listed on the aide care plan. ■ Patient’s plan of care was not updated when the agency received authorization for an increase in aides services from 10 hours/week to 40 hours/week. Compliance tips for: Nerd Newbies (understand the requirement) ■ Each client/patient referred for aide services is assessed by an RN (HC5-3D) and a written plan of care is established based on the assessment data. The plan of care specifies services to be provided by each discipline involved and include the frequency, duration, and expected outcomes.
■ The plan of care order for nursing services indicates 3-4 hours daily, 7 days a week. Hours documented were spread throughout the week but not provided daily. ■ There was documentation of tasks (foot/nail care, assist with transfer, full lift, hoyer lift, assist feeding) that were not assigned. ■ The plan of care included an order for nursing services once a week for four weeks for B12 injection but after the initial order date, there was no evidence of nursing visits. ■ Nursing notes indicated that bilateral lower extremity wounds were healed. RN frequency was changed and wound care ended. There was no evidence that the physician was notified or ordered the change. Compliance tips for:
■ Audit client/patient records to ensure that aide responsibilities are clearly delineated as an individual plan of care and that performance of tasks aligns with those ordered. ■ Review any additional forms your agency uses for documentation of aide services (task list/time sheet) for alignment with content in plans of care to improve traceability of entries related to the timing and performance of tasks.
Nerd Apprentices (audit for excellence)
■ This standard represents the implementation of the plan of care across all disciplines ordered. Meeting the standard shows that each role involved in delivering care to an individual client/patient can understand the full scope of that client/patient’s goals for care. ■ If care is not documented, there is no evidence that it occurred.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
■ Audit records to ensure that: ٝ services are documented.
Nerd Apprentices (audit for excellence)
ٝ documented services align with plans of care. ٝ all personnel on the care team can coordinate to support the client/ patient in achieving the goals of their care. ٝ when ordered care was not provided, a reason (including patient refusal) is documented. ■ Present examples at an in-service training of how service coordination has benefited specific (de-identified) clients/patients. When staff understand the connection between services, it encourages collaboration for improvement.
HC5-3K Frequency of the citation: 40%
Overview of the requirement: Services are delivered according to the individual client/patient plan of care. Client/patient records reflect accurate and complete documentation of services delivered so that each discipline involved has a sightline to ensure coordination of care. Comment on deficiencies: Compliance is assessed through review of policies, procedures, and client/patient records. This is the standard most frequently cited for non-compliance in Home Care Accreditation services. Most deficiencies resulted from missing documentation that plan of care tasks were performed or from documentation of tasks that were not part of the plan of care assignments. Examples of ACHC Surveyor findings: ■ Staff noted times in and out but did not document care provided. ■ Aide services are ordered MWF 7:30am-5:00pm but there are four weeks during the period of services without documentation of any aide visits. ■ The plan of care includes an order for physical therapy three times a week for four weeks (PT 3W4), but weeks 3 and 4 had only two visits documented.
Nerd Trailblazers (prepare the path for others)
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Compliance tips for:
HC5-3L Frequency of the citation: 17%
■ The RN (or qualified professional) plan of care review involves the client/ patient to assess for changes in their condition, their satisfaction with services, and to confirm whether: ٝ All plan of care Aide Services are being provided. ٝ All plan of care Aide Services continue to be needed. ٝ The client/patient outcomes indicate that the care/services are effective. ■ Reassessment and review takes place every 90 days or more frequently if required by the state. ■ Review policies and procedures to ensure that reassessment and review for Aide plans of care occurs at the more frequent of the state requirement or every 90 days. ■ Audit client/patient records to ensure that RNs or qualified individuals are documenting the required elements including: ٝ All services are provided.
Nerd Newbies (understand the requirement)
Overview of the requirement: Each client/patient receiving Aide Services is reassessed by an RN or other qualified professional at least every 90 days* and their plan of care is reviewed and revised based on this reassessment.
*State laws that require more frequent reviews supersede this time frame. Note: This standard applies to Home Care Aide (HCA) services only.
Comment on deficiencies: Compliance is evaluated through interviews and review of client/patient records. Most surveyor findings indicated variance from state requirements for more frequent reassessment and plan of care review. Other deficiencies reflected gaps in plan of care review extending beyond 90 days. Examples of ACHC Surveyor findings: ■ Client/patient records reflect plan of care reviews less frequently than every 90 days, with gaps ranging from four to seven months between some reassessments/reviews. ■ Agency was not in compliance with state-specific requirements for a more stringent review time frame of every 60 days. ■ The record noted a request from the client/patient for a change that was implemented on the aide schedule but not updated on the plan of care. ■ The record noted a request from the family that the aide encourage fluids at every visit but this was not noted on the original plan of care, or the reassessment revision. ■ The state requires evidence that the client/patient has been queried as to the adequacy and implementation of the plan of care at least every 30 days with responses noted. The agency’s records for four of five clients/patients did not include this documentation.
Nerd Apprentices (audit for excellence)
ٝ Services are needed. ٝ Services are effective. ٝ Reassessment notes changes (or none) in the client/patient’s condition.
■ Audit records for documentation that the client/patient was involved in the reassessment and review. Note that some states require patient interviews more frequently than full reassessment and review. ■ Create a process, such as calendar reminders to ensure that plans of care are reviewed by the RN every 90 days at minimum or per state requirement. ■ Ensure that policies and procedures are updated to reflect new process. ■ Regularly review state requirements to ensure continued compliance.
Nerd Trailblazers (prepare the path for others)
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SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HH5-1A Frequency of the citation: 22% Overview of the requirement: Each patient has an individual record with documentation of each home visit, treatment, or care/service. Entries are legible, clear, complete, and appropriately authenticated, dated, and timed. Signatures include the proper designation of any credentials. Comment on deficiencies: Compliance is assessed through review of patient records. Because of the level of detail required most deficiencies identified individual items that were missing. Incomplete authentication of entries (legible signatures with credentials, date, and time noted) was the dominant theme. Examples of ACHC Surveyor findings: ■ Referral information describing the patient’s history, hospital stays (if any), provider visit notes, and reason for referral was missing from the records. ■ Start of care (SOC) paperwork does not include credentials, date, or time with the signature. ■ SOC OASIS is electronically signed and dated, but the signature does not include the discipline. The Administrator recognized that this was an error in how the clinicians were set up in the EMR and corrected it prior to the close of survey. ■ All clinical notes were missing skilled nurse credentials (RN, LVN). Agency found EMR software issue preventing credentials from being displayed and is working with software vendor to resolve. ■ Physical therapy and skilled nursing visit notes did not document the patient response to treatment. ■ Agency policy for clinical note completion is “within 48 hours of visit.” PT visit note completion for records reviewed ranged from seven days to one month. ■ Advance directives is unmarked on patient admission consent form. ■ Signatures are missing from recertification orders. ■ Paper records provided to the surveyor had no visit notes. When brought to the agency’s attention, the notes were accessed from an email and provided to the surveyor for review. ■ Paper records included stamped signatures, especially for verbal orders.
HOME HEALTH SERVICES AND DISTINCTIONS Services Home Health Aide
Distinctions Age-Friendly Care Behavioral Health Outcomes
Palliative Care Telehealth
Physical Therapy Skilled Nursing Speech Therapy
Medical Social Services Occupational Therapy
FREQUENT DEFICIENCIES FROM HOME HEALTH SURVEYS
60%
50%
40%
30%
20%
10%
0%
HH5-1A
HH5-2F
HH5-3A
HH5-6A
HH5-11A
Provision of Care and Record Management
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■ The plan of care goal summary states, “No goals have been assigned to this patient.” The Progress to Goals section is blank. ■ SN and aide visits do not include a time in/time out.
HH5-2F Frequency of the citation: 48%
Overview of the requirement: A medication profile is part of the comprehensive assessment and includes ongoing review of all medications the patient is currently using. A medication review to identify potential adverse effects is documented in the patient record by an RN (or by a PT, OT, or speech-language pathologist for therapy- only cases). Conclusions of the review are documented in the patient’s record. Comment on deficiencies: Compliance is evaluated through home visits, response to interviews, and review of policies, procedures, and patient records. Most deficiencies noted incomplete orders, with elements such as dose, frequency, route, location, and diluent missing. Home visits frequently revealed discrepancies between the profile and the medications actually being taken. Examples of ACHC Surveyor findings: ■ Medication profiles reveal incomplete orders with no indicators for PRN. For example, list includes, "Gabapentin 100mg cap by mouth 2 times per day PRN, Tylenol extra strength 500mg tab by mouth as needed, Tramadol 50 mg 1 tab po every 6 hrs. as needed." No PRN/as needed reason ■ Medication profile indicates, “Carvedilol 3.15mg one tablet two times daily." During the home visit it was found that the patient is taking Metoprolol 25mg daily and Carvedilol was discontinued. Patient's wife stated this was not a new change as patient has been on this medication “awhile now.” ■ During home visit, patient stated he takes Cinnamon 1000mg 2 tabs daily and a multivitamin. He states he has taken both "for a long time." These were not found on the medication profile.
Compliance tips for:
The goal of this standard is to ensure continuity of care. Documentation of care plans, care delivered, and the patient’s response to treatment must be complete and traceable to a provider at a level of specificity that makes information accessible to any subsequent provider. ■ Each home visit must be documented and signed by the individual who provided the care/services. ■ Signatures are signed, dated, legible, legal, and include credentials.
Nerd Newbies (understand the requirement)
■ Electronic signatures are acceptable. ■ Signature stamps are not acceptable.
■ Audit for complete patient records. Required elements include (but are not limited to): ٝ Comprehensive assessment. ٝ Plans of care. ٝ Physician or allowed practitioner orders. ٝ All interventions and the patients’ response to interventions/care. ٝ Goals and patient progress toward goals. ٝ Identifying information. ٝ Contact information for the health care professional responsible for care/services after discharge. ٝ Signed and dated clinical and progress notes. ٝ Discharge/transfer summaries. ٝ Copies of summaries sent to the attending physician or allowed practitioner. ■ When audits reveal missing documentation, continue to an analysis. Are errors specific to a particular discipline? To individual providers? If so, plan focused training sessions. ■ If your agency uses electronic records, ensure that credentials are automatically associated with electronic provider signatures.
Nerd Apprentices (audit for excellence)
■ Patient on O2@2L/minute. Not found on the medication profile. ■ Medication profile did not document allergies (or lack thereof).
Nerd Trailblazers (prepare the path for others)
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Compliance tips for:
Examples of ACHC Surveyor findings: ■ Plan of care (POC) does not include all types of services ordered. Referral indicates home health for SN, PT, OT. ■ Oxygen is in use but is not listed on the POC. ■ Medications listed on the plan of care are delivered subcutaneously. Safety measures do not include sharps safety. ■ The medication list includes IV medications without indicating the diluent, total volume, rate, or method of infusion. ■ Opioids are prescribed PRN without identifying a reason. ■ Order for catheter change did not include size of catheter and balloon, type of catheter, and when next catheter change is due. ■ Skilled nursing interventions and goals are missing. ■ POC goals state: “Pt will be able to identify correct dose route and frequency of each medication before end of episode and will be independent in med management by the end of episode.” Assessment documentation indicates “Patient is independent at self-administration of medication at admission.” POC includes “Patient will be free from pain during this cert period and will express pain less than 9 in 9 weeks.” Pain is documented as “not a problem for patient.” No reported acute pain or history of pain documented in record. ■ Plan of care includes blood glucose parameters to report to the physician. The patient does not have a diagnosis of diabetes or medication use for hyperglycemia. The order is not relevant to the patient’s medical status. ■ There is no documentation that the physician was consulted to approve the plan of care. ■ Orders failed to identify the discipline and frequency of care. ■ Plan of care did not include interventions or goals for home health aide but had a frequency.
The intent of this standard is patient safety. Through regular review of prescribed and OTC medications, home health staff are positioned to identify potential adverse effects and interactions. The profile is not a “one-and-done” situation. The standard states that drug regimen review is an ongoing part of patient care.
Nerd Newbies (understand the requirement)
■ A complete medication profile includes: ٝ All current patient medications. ٝ Date prescribed or taken ٝ Medication name ٝ Dose, route, frequency ٝ Date discontinued (if applicable) ٝ Drug or food interactions
■ Audit medication profiles with an eye toward incomplete orders to ensure accuracy and completion.
Nerd Apprentices (audit for excellence)
■ Reeducate staff on the responsibility to review all medications the patient is currently using and that review is a regular part of care. ■ When incomplete orders are noted, e.g., no indicators for PRN, best practice would require follow-up with the prescriber for additional detail to be added to the order.
Nerd Trailblazers (prepare the path for others)
HH5-3A Frequency of the citation: 57%
Overview of the requirement: Each patient has an individualized plan of care developed in consultation with the patient, physician (or allowed practitioner), and agency staff. The initial plan results from the comprehensive assessment, includes the discipline(s) providing care, measurable outcomes, and updates reflect revisions or additions. Comment on deficiencies: Compliance is evaluated through review of policies, procedures, and patient records. The plan of care requires consistent communication between multiple disciplines. This is a frequent deficiency due to the number of elements that must be included in the documentation. Most deficiencies resulted from incomplete medication orders or other missing information.
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Compliance tips for: Nerd Newbies
HH5-11A Frequency of the citation: 47%
This is consistently the most frequently cited deficiency on home health agency surveys because of the number of distinct elements that must be documented in the initial plan of care. ■ Required information that looks back includes demographic data, orders that initiate care, identified risks for the patient, advance directive. ■ Categories of information that address the present include diagnoses, medication profile, results of initial and ongoing assessments, equipment/ supply needs, therapy orders, patient/caregiver education, services provided, patient response to treatment/therapies. ■ Forward looking items include goals and changes in potential to achieve these, new and revised orders, goals, certification end/renewal date. This is not a comprehensive list, but a way to think about the elements that can help ensure a comprehensive and individualized plan of care for each patient.
(understand the requirement)
Overview of the requirement: The agency furnishes skilled professional services. Individuals delivering these services must participate in the coordination of care and assume responsibility for ongoing assessment, accurate documentation, patient/caregiver education, implementation of orders outlined in the plan of care, and several additional tasks defined in the standard. . Comment on deficiencies: Evidence of compliance is found in job descriptions, personnel files, patient records, and through direct observation. Most deficiencies identified gaps between orders and documentation of care provided, indicating a failure to adequately assume responsibility for care. Examples of ACHC Surveyor findings: ■ Orders included medication reconciliation on every visit but visit notes did not reflect that this was performed. ■ POC states “notify physician of fasting blood sugar greater that (>) 200 or less than (<) 70 . Random blood sugar greater than (>) 250 or less than (<) 70.” No SN visit notes include documentation of blood sugar assessment. ■ POC states “monitor/perform weekly weight (due to obesity) and report any gain/loss of more than 5 lbs per week.” The SN did not document weight weekly, but on consecutive weeks when it was documented, there was no evidence in the patient chart that the physician was notified of an 11 lb. decrease in weight. ■ Patient records did not have evidence that RN performed supervision on the LVN at least every 60 days. ■ OASIS/comprehensive assessment indicates, “Other services involved: PT.” No supporting documentation that physical therapy was ordered or assigned to the patient. Inaccurate documentation. ■ SN documented primary language of patient in Oasis/Comprehensive Adult Nursing Assessment as English. The POC documents the patient’s primary language as Armenian. ■ Clinical notes included improper use of medical abbreviations per agency policy for documenting medications.
■ Audit plans of care.
Nerd Apprentices (audit for excellence)
ٝ The home health agency is responsible for obtaining orders prior to start of care. ٝ The plan of care must be consistent with practitioner orders. ٝ Review for goals that include measurable outcomes with evidence of patient involvement. ٝ Medication lists must be comprehensive of prescribed and OTC drugs and include dose, frequency, and route. ٝ Look for supplies, equipment, related safety issues, and evidence of education/training associated with each order. ■ Create a plan of care checklist to facilitate complete and comprehensive patient records. ■ Use supervisory home visits to check the medication profile against drugs, equipment, and supplies on hand and interview patients/caregivers to verify compliance and accuracy.
Nerd Trailblazers (prepare the path for others)
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SURVEYOR
HOME HEALTH
NOTES
Compliance tips for:
This standard ties orders to specific disciplines with the expectation that the qualified individuals providing services assume responsibility for all tasks associated with the order. This includes not only performance of the task, but complete documentation of its performance, and communication with the ordering provider as indicated in the order.
Nerd Newbies (understand the requirement)
■ Audit patient records for completion and accuracy:
Nerd Apprentices (audit for excellence)
ٝ All services ordered are delivered as ordered and documented in clinical notes. ٝ Health care professionals conduct ongoing interdisciplinary assessment of the patient. ٝ Patients and caregivers are counseled and educated. ٝ Communication with physicians or other ordering practitioners involved with the plan of care is documented. ٝ Supervisory visits are documented. ■ Audit personnel records for complete and accurate job descriptions: ٝ RNs oversee the work of LPNs and LVNs. ٝ MSWs oversee the work of social workers. ٝ Rehabilitative therapy is proved under the supervision of a qualified OT or PT. ٝ Staff participate in the agency’s QAPI Program. ٝ Staff participate in in-service training. ■ Plan and execute in-service training related to documentation best practice. ٝ .Include how to communicate with ordering providers. ■ Ensure an approved abbreviation list is current and used by staff.
Nerd Trailblazers (prepare the path for others)
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Volume 2025 | No. 2
SURVEYOR
HOSPICE
SECTION 4: HUMAN RESOURCES MANAGEMENT HSP4-13A Frequency of the citation: 49%
Overview of the requirement: Hospice aides follow written care instructions for individual patients as assigned by a registered nurse who maintains responsibility for supervision of the aide. The RN making aide assignments is a member of the interdisciplinary group. Comment on deficiencies: Evidence of compliance is assessed through review of patient records and direct observations of care. Many deficiencies were cited because the aide plan of care and the aide visit notes did not match. In some cases, this was related to the frequency and in others, to the specific tasks performed, e.g., not ordered, or ordered but not performed. Finally, some deficiencies noted a change in the plan of care that was not documented. Examples of ACHC Surveyor findings: ■ The number of documented weekly aide visits did not match the number of visits ordered. ■ During the home visit, the aide stated that she shampoos the patient’s hair weekly. Weekly shampoo is not listed on the aide care plan. ■ Aide care plan identifies tasks to be performed at each visit, e.g., shower, shave, oral care, dress, change linen every visit. On specific visit dates, aide documented “not applicable.” ■ For tasks not completed, the aide did not document a reason. ■ Nail care is listed as a weekly task. It was documented as performed at all three weekly visits. ■ Aide visit frequency on the plan of care is 2w11. Patient was admitted to IPU with 24h/7d week aide care provided.
Services Hospice Care Hospice Inpatient Care HOSPICE SERVICES AND DISTINCTIONS Distinctions Age-Friendly Care Palliative Care Telehealth
FREQUENT DEFICIENCIES IN HOSPICE AGENCIES
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Compliance tips for:
■ Hospice aides must limit services to those that are ordered by the IDG and included in the plan of care. ■ All services in the aide plan of care are expected to be performed and documented at the frequency noted in the plan. ■ Hospice aides and supervising RNs are expected to maintain effective communication with regard to the patient’s medical, nursing, rehabilitative, and social needs. Compliance with policies for documentation in patient records is a critical aspect of compliance.
Nerd Newbies (understand the requirement)
HSP4-13A
HSP5-1A
HSP5-3C
HSP5-3D
HSP5-4A
HSP5-4B
HSP5-4F
Human Resources Management
Provision of Care and Record Management
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Volume 2025 | No. 2
SURVEYOR
HOSPICE
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HSP5-1A Frequency of the citation: 49% Overview of the requirement: Each home visit, treatment, or care/service is documented in an individual patient record. Entries are legible, clear, complete, and appropriately authenticated, dated, and timed. Signatures include the proper designation of any credentials. Specific items, including the detailed statement of election of hospice services, are included in each record. Comment on deficiencies: Compliance is assessed through review of patient records. Surveyors verify that patient records contain all required items detailed in the standard. Because of the level of detail required for compliance with this standard, most deficiencies cited identified one or more specific item that was missing. Incomplete authentication of entries (legible signatures with credentials, date, and time noted) was the dominant theme. Examples of ACHC Surveyor findings: ■ Patient records include signed and dated forms to identify services covered by hospice care, but the forms themselves are not completed. ■ The hospice notice of election includes no start of care date/no indication of signer’s relationship to patient. "I do not wish to choose an attending physician" and "my choice for attending physician is" are both chosen. "I acknowledge my attending physician is" is selected but with no physician name noted. ■ The SN documented “Oxygen in home is safely stored and pt understands use.” Patient is not on oxygen. ■ IDG meeting notes are not electronically signed by all team members. ■ Initial comprehensive assessment narrative includes “educated PCG regarding wound care.” There is no documented evidence that patient had wounds. Integumentary status is documented as “normal, cool, warm, dry, fair turgor, wound/skin impairment – no” and identified as low risk for skin impairment. ■ Notes regarding new order for Rocephin injections IM for 3 days says simply “Noted and carried out. IDG team aware.” No visit note to reflect administration of antibiotic and/or who administered. No documented order. Not listed on Rx profile.
■ Audit patient records for documentation that hospice aides provide services that are: ٝ .Ordered by the interdisciplinary group. ٝ Included in the plan of care. ٝ Permitted to be performed under state law by such hospice aide. ٝ Consistent with the hospice aide training. ■ Audit patient records and work with the RN to update plans of care when needed. ■ Observe and assess aide visits to ensure consistency between tasks and orders. ■ Educate staff on proper visit documentation, including the use of “PRN” or “per patient choice.” Whether for personal or nonpersonal care tasks, the use of these terms is unacceptable, unless the RN has documented that the patient is cognitively and functionally able to make the decision.
Nerd Apprentices (audit for excellence) continued
Nerd Trailblazers (prepare the path for others)
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Volume 2025 | No. 2
SURVEYOR
HOSPICE
Compliance tips for:
HSP5-3C Frequency of the citation: 40%
The intent of this standard is that each patient’s clinical record is accurate, complete and available to the patient’s attending physician and the hospice staff. This includes timely filing of election and assessment documents, as well as properly authenticated initial and updated plans of care, IDG meeting notes, orders, and clinical and progress notes. ■ Review election statements to ensure all items are present and completed correctly. ■ Audit for complete patient records. Required elements include (but are not limited to): ٝ Identifying information. ٝ Physician certification and recertification of terminal illness. ٝ Signed copy of the election of hospice services. ٝ Advance directives. ٝ Initial assessment and comprehensive assessment. ٝ Initial and updates plans of care. ٝ Signed copy of the statement of patient rights. ٝ Physician orders. ٝ All care and services provided and the patients’ response to medications, symptom management, treatments, and services. ٝ Check and recheck entries for accuracy. Correct typos and use clear language. ■ Establish a list of abbreviations that are approved by the agency for use in clinical records. ■ Educate all members of the interdisciplinary to authenticate meeting notes. ■ Check progress note entries for timeliness. Misalignment of notes and plans of care may be the result of delays in documentation.
Nerd Newbies (understand the requirement)
Overview of the requirement: The hospice interdisciplinary team must complete a written, patient-specific assessment within five calendar days of the election of hospice care. The comprehensive assessment considers physical health, mental health, functional limitations, pain management, and social, environmental, and economic components. A bereavement assessment is conducted, and the patient’s and family’s spiritual needs are evaluated. Comment on deficiencies: Evidence of compliance is based on review of patient records. Most deficiencies noted either: assessments were completed beyond the five calendar day requirement or assessments were missing specific components (usually spiritual/bereavement needs or psycho/social assessment). Examples of ACHC Surveyor findings: ■ The comprehensive assessment lacked a bereavement component to address the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. ■ The comprehensive assessment was completed 14 days after the patient was admitted to services. ■ The record indicates the chaplain met with patient to perform the spiritual assessment. Documentation states chaplain met with a wife and a friend as patient is unable to verbalize. Documentation states patient and care concerns were discussed. There is no detail regarding the concerns or needs. ■ No evidence that the components of the assessment were completed by qualified disciplines.
Nerd Apprentices (audit for excellence) continued
Nerd Trailblazers (prepare the path for others)
Compliance tips for:
The acceptance of hospice care can be an emotionally stressful decision for a patient and/or their family. The intent of this standard is to ensure that the interdisciplinary group completes a comprehensive and timely assessment. This supports palliation and management of the terminal illness founded on consideration of the comfort and dignity of the patient and the needs of the family and others.
Nerd Newbies (understand the requirement)
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Volume 2025 | No. 2
SURVEYOR
HOSPICE
■ Monitor time frames to ensure completion of comprehensive assessments within five calendar days of the election of hospice care ■ Audit patient records to ensure inclusion of:
Nerd Apprentices (audit for excellence) continued
Frequency of the citation: 54%
Overview of the requirement: A registered nurse creates and maintains a medication profile by reviewing all prescription and over- the-counter drugs, herbal remedies, and alternative treatments that could affect drug therapy. The interdisciplinary group (IDG) reviews the profile at each meeting and additionally, as needed. Comment on deficiencies: Evidence of compliance is assessed through response to interviews, observation of home visits, and review of patient records, policies, and procedures. Surveyors noted specific inconsistent, incomplete, and accurate medication profiles as evidenced by: ■ Medications with incomplete instruction as to dose, frequency, diluent, route, application location, or purpose.
ٝ Demographic information. ٝ Physical health assessment. ٝ Functional limitations. ٝ Pain and symptom assessments. ٝ Mental health assessment. ٝ Social assessment. ٝ Home environment, including emergency preparedness plan assessment. ٝ Economic assessment. ٝ Spiritual assessment. ٝ Bereavement assessments. ٝ Evidence that qualified personnel conducted assessments.
■ Discontinued medications that remain on the profile as active. ■ Medications ordered that are not present on the medication profile.
■ Educate staff about how to handle refusal of an assessment component. If the patient or their family declines to speak to a specific discipline, e.g., a chaplain or social worker, those components of the comprehensive assessment are still required. Other professional staff who have built relationships may be able to elicit information needed to promote well- being, comfort, and dignity throughout the dying process and identify the spiritual, psycho-social, and bereavement needs of the patient and family.
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings: ■ Patient records include treatment orders for oxygen. Oxygen is not noted on the medication list. ■ Medication profile includes oxygen delivery rate that differs from the rate documented on nursing visits. ■ Medication instructions state, “Benadryl 2% topical gel. Apply one inch to affected area twice daily as needed for rash” with no indication of the application site. ■ The record includes duplicate medication entries with varying instructions for dosage. ■ During patient interview at home visit, the patient stated that she takes 25mg labetalol rather than the 100mg listed on the medication profile, lactulose PRN rather than scheduled twice daily, and had not taken Lyrica for two weeks. ■ Patient record has order for triple antibiotic cream to be applied to stage 2 skin tear. This medication is not on medication profile. ■ Medications ordered for specific periods (10 days) remained active on the medication profile beyond the period of administration. ■ Wound care medication remains current for a wound that has been noted as resolved on plan of care. ■ The medication profile includes entries for different forms of acetaminophen: 500mg - 2 tabs every 4 hours as needed for pain and 650 mg suppository every 6 hours as needed for pain with no instruction not to exceed 4000 mg of acetaminophen daily.
HSP5-3D
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