Volume 2025 | No. 2
SURVEYOR
HOME CARE
■ 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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