Volume 2025 | No. 2
SURVEYOR
HOSPICE
Compliance tips for:
HSP5-3C Frequency of the citation: 40%
The intent of this standard is that each patient’s clinical record is accurate, complete and available to the patient’s attending physician and the hospice staff. This includes timely filing of election and assessment documents, as well as properly authenticated initial and updated plans of care, IDG meeting notes, orders, and clinical and progress notes. ■ Review election statements to ensure all items are present and completed correctly. ■ Audit for complete patient records. Required elements include (but are not limited to): ٝ Identifying information. ٝ Physician certification and recertification of terminal illness. ٝ Signed copy of the election of hospice services. ٝ Advance directives. ٝ Initial assessment and comprehensive assessment. ٝ Initial and updates plans of care. ٝ Signed copy of the statement of patient rights. ٝ Physician orders. ٝ All care and services provided and the patients’ response to medications, symptom management, treatments, and services. ٝ Check and recheck entries for accuracy. Correct typos and use clear language. ■ Establish a list of abbreviations that are approved by the agency for use in clinical records. ■ Educate all members of the interdisciplinary to authenticate meeting notes. ■ Check progress note entries for timeliness. Misalignment of notes and plans of care may be the result of delays in documentation.
Nerd Newbies (understand the requirement)
Overview of the requirement: The hospice interdisciplinary team must complete a written, patient-specific assessment within five calendar days of the election of hospice care. The comprehensive assessment considers physical health, mental health, functional limitations, pain management, and social, environmental, and economic components. A bereavement assessment is conducted, and the patient’s and family’s spiritual needs are evaluated. Comment on deficiencies: Evidence of compliance is based on review of patient records. Most deficiencies noted either: assessments were completed beyond the five calendar day requirement or assessments were missing specific components (usually spiritual/bereavement needs or psycho/social assessment). Examples of ACHC Surveyor findings: ■ The comprehensive assessment lacked a bereavement component to address the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. ■ The comprehensive assessment was completed 14 days after the patient was admitted to services. ■ The record indicates the chaplain met with patient to perform the spiritual assessment. Documentation states chaplain met with a wife and a friend as patient is unable to verbalize. Documentation states patient and care concerns were discussed. There is no detail regarding the concerns or needs. ■ No evidence that the components of the assessment were completed by qualified disciplines.
Nerd Apprentices (audit for excellence) continued
Nerd Trailblazers (prepare the path for others)
Compliance tips for:
The acceptance of hospice care can be an emotionally stressful decision for a patient and/or their family. The intent of this standard is to ensure that the interdisciplinary group completes a comprehensive and timely assessment. This supports palliation and management of the terminal illness founded on consideration of the comfort and dignity of the patient and the needs of the family and others.
Nerd Newbies (understand the requirement)
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