Volume 2025 | No. 2
SURVEYOR
HOSPICE
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HSP5-1A Frequency of the citation: 49% Overview of the requirement: Each home visit, treatment, or care/service is documented in an individual patient record. Entries are legible, clear, complete, and appropriately authenticated, dated, and timed. Signatures include the proper designation of any credentials. Specific items, including the detailed statement of election of hospice services, are included in each record. Comment on deficiencies: Compliance is assessed through review of patient records. Surveyors verify that patient records contain all required items detailed in the standard. Because of the level of detail required for compliance with this standard, most deficiencies cited identified one or more specific item that was missing. Incomplete authentication of entries (legible signatures with credentials, date, and time noted) was the dominant theme. Examples of ACHC Surveyor findings: ■ Patient records include signed and dated forms to identify services covered by hospice care, but the forms themselves are not completed. ■ The hospice notice of election includes no start of care date/no indication of signer’s relationship to patient. "I do not wish to choose an attending physician" and "my choice for attending physician is" are both chosen. "I acknowledge my attending physician is" is selected but with no physician name noted. ■ The SN documented “Oxygen in home is safely stored and pt understands use.” Patient is not on oxygen. ■ IDG meeting notes are not electronically signed by all team members. ■ Initial comprehensive assessment narrative includes “educated PCG regarding wound care.” There is no documented evidence that patient had wounds. Integumentary status is documented as “normal, cool, warm, dry, fair turgor, wound/skin impairment – no” and identified as low risk for skin impairment. ■ Notes regarding new order for Rocephin injections IM for 3 days says simply “Noted and carried out. IDG team aware.” No visit note to reflect administration of antibiotic and/or who administered. No documented order. Not listed on Rx profile.
■ Audit patient records for documentation that hospice aides provide services that are: ٝ .Ordered by the interdisciplinary group. ٝ Included in the plan of care. ٝ Permitted to be performed under state law by such hospice aide. ٝ Consistent with the hospice aide training. ■ Audit patient records and work with the RN to update plans of care when needed. ■ Observe and assess aide visits to ensure consistency between tasks and orders. ■ Educate staff on proper visit documentation, including the use of “PRN” or “per patient choice.” Whether for personal or nonpersonal care tasks, the use of these terms is unacceptable, unless the RN has documented that the patient is cognitively and functionally able to make the decision.
Nerd Apprentices (audit for excellence) continued
Nerd Trailblazers (prepare the path for others)
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