Volume 2025 | No. 2
SURVEYOR
HOME HEALTH
■ 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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