Surveyor Newsletter 2025 | Quality Review, HC HH, HIT, HSP

Volume 2025 | No. 2

SURVEYOR

HOME CARE

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 Apprentices (audit for excellence)

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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