Volume 2025 | No. 2
SURVEYOR
HOME CARE
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)
achc.org | (855) 937-2242 | 13
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