Volume 2025 | No. 2
SURVEYOR
HOME HEALTH
Compliance tips for: Nerd Newbies
HH5-11A Frequency of the citation: 47%
This is consistently the most frequently cited deficiency on home health agency surveys because of the number of distinct elements that must be documented in the initial plan of care. ■ Required information that looks back includes demographic data, orders that initiate care, identified risks for the patient, advance directive. ■ Categories of information that address the present include diagnoses, medication profile, results of initial and ongoing assessments, equipment/ supply needs, therapy orders, patient/caregiver education, services provided, patient response to treatment/therapies. ■ Forward looking items include goals and changes in potential to achieve these, new and revised orders, goals, certification end/renewal date. This is not a comprehensive list, but a way to think about the elements that can help ensure a comprehensive and individualized plan of care for each patient.
(understand the requirement)
Overview of the requirement: The agency furnishes skilled professional services. Individuals delivering these services must participate in the coordination of care and assume responsibility for ongoing assessment, accurate documentation, patient/caregiver education, implementation of orders outlined in the plan of care, and several additional tasks defined in the standard. . Comment on deficiencies: Evidence of compliance is found in job descriptions, personnel files, patient records, and through direct observation. Most deficiencies identified gaps between orders and documentation of care provided, indicating a failure to adequately assume responsibility for care. Examples of ACHC Surveyor findings: ■ Orders included medication reconciliation on every visit but visit notes did not reflect that this was performed. ■ POC states “notify physician of fasting blood sugar greater that (>) 200 or less than (<) 70 . Random blood sugar greater than (>) 250 or less than (<) 70.” No SN visit notes include documentation of blood sugar assessment. ■ POC states “monitor/perform weekly weight (due to obesity) and report any gain/loss of more than 5 lbs per week.” The SN did not document weight weekly, but on consecutive weeks when it was documented, there was no evidence in the patient chart that the physician was notified of an 11 lb. decrease in weight. ■ Patient records did not have evidence that RN performed supervision on the LVN at least every 60 days. ■ OASIS/comprehensive assessment indicates, “Other services involved: PT.” No supporting documentation that physical therapy was ordered or assigned to the patient. Inaccurate documentation. ■ SN documented primary language of patient in Oasis/Comprehensive Adult Nursing Assessment as English. The POC documents the patient’s primary language as Armenian. ■ Clinical notes included improper use of medical abbreviations per agency policy for documenting medications.
■ Audit plans of care.
Nerd Apprentices (audit for excellence)
ٝ The home health agency is responsible for obtaining orders prior to start of care. ٝ The plan of care must be consistent with practitioner orders. ٝ Review for goals that include measurable outcomes with evidence of patient involvement. ٝ Medication lists must be comprehensive of prescribed and OTC drugs and include dose, frequency, and route. ٝ Look for supplies, equipment, related safety issues, and evidence of education/training associated with each order. ■ Create a plan of care checklist to facilitate complete and comprehensive patient records. ■ Use supervisory home visits to check the medication profile against drugs, equipment, and supplies on hand and interview patients/caregivers to verify compliance and accuracy.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 21
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