Volume 2025 | No. 2
SURVEYOR
HOSPICE
SECTION 4: HUMAN RESOURCES MANAGEMENT HSP4-13A Frequency of the citation: 49%
Overview of the requirement: Hospice aides follow written care instructions for individual patients as assigned by a registered nurse who maintains responsibility for supervision of the aide. The RN making aide assignments is a member of the interdisciplinary group. Comment on deficiencies: Evidence of compliance is assessed through review of patient records and direct observations of care. Many deficiencies were cited because the aide plan of care and the aide visit notes did not match. In some cases, this was related to the frequency and in others, to the specific tasks performed, e.g., not ordered, or ordered but not performed. Finally, some deficiencies noted a change in the plan of care that was not documented. Examples of ACHC Surveyor findings: ■ The number of documented weekly aide visits did not match the number of visits ordered. ■ During the home visit, the aide stated that she shampoos the patient’s hair weekly. Weekly shampoo is not listed on the aide care plan. ■ Aide care plan identifies tasks to be performed at each visit, e.g., shower, shave, oral care, dress, change linen every visit. On specific visit dates, aide documented “not applicable.” ■ For tasks not completed, the aide did not document a reason. ■ Nail care is listed as a weekly task. It was documented as performed at all three weekly visits. ■ Aide visit frequency on the plan of care is 2w11. Patient was admitted to IPU with 24h/7d week aide care provided.
Services Hospice Care Hospice Inpatient Care HOSPICE SERVICES AND DISTINCTIONS Distinctions Age-Friendly Care Palliative Care Telehealth
FREQUENT DEFICIENCIES IN HOSPICE AGENCIES
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Compliance tips for:
■ Hospice aides must limit services to those that are ordered by the IDG and included in the plan of care. ■ All services in the aide plan of care are expected to be performed and documented at the frequency noted in the plan. ■ Hospice aides and supervising RNs are expected to maintain effective communication with regard to the patient’s medical, nursing, rehabilitative, and social needs. Compliance with policies for documentation in patient records is a critical aspect of compliance.
Nerd Newbies (understand the requirement)
HSP4-13A
HSP5-1A
HSP5-3C
HSP5-3D
HSP5-4A
HSP5-4B
HSP5-4F
Human Resources Management
Provision of Care and Record Management
achc.org | (855) 937-2242 | 25
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