Volume 2025 | No. 2
SURVEYOR
HOME CARE
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
achc.org | (855) 937-2242 | 15
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