Volume 2025 | No. 2
SURVEYOR
HOSPICE
HSP5-4B Frequency of the citation: 46%
HSP5-4F Frequency of the citation: 29%
Overview of the requirement: Services provided match the plan of care.
Overview of the requirement: The IDG reviews plans of care based on reassessments that occur every 15 calendar days or more frequently as the patient’s condition requires. Comment on deficiencies: Evidence of compliance is found in response to interviews and documentation in patient records. Surveyors noted a lack of evidence that IDG review occurred every 15 days and that there was effective communication with the IDG to inform updates to the plan of care. Examples of ACHC Surveyor findings: ■ During the home visit attended by the Surveyor, the RN stated that the patient was taking only Ensure and water orally, for approximately the past 1-2 months. The IDG plan of care includes, “Offer food/fluids as tolerated and supplements as ordered” and “teach caregiver importance of diet in maintenance of adequate bowel function.” Ensure was not noted on the POC. ■ The RN start of care assessment noted that the patient had a history of coccyx pressure ulcers. The plan of care Problem/Intervention/Goal section does not note pressure ulcers as an active area of potential concern. ■ There was no documentation of IDG collaboration with the attending physician every 15 days. ■ The record indicates the daughter raised concern about the patient’s pain. There was no evidence that the plan of care was individualized to include the type of pain assessment necessary for the patient’s memory loss and inability to communicate. There was no evidence of goals to achieve measurable pain control. ■ IDG notes have no evidence of summarized care of the previous two weeks by RN or MSW. ■ Patient’s last documented IDG review was on 07/30. Patient passed 08/27. ■ IDG has an RN note and signature only. No identification of a Spiritual Care/Counselor or physician, who is actively participating in care.
Comment on deficiencies: Compliance is evaluated through review of patient records. Some issues were noted for care that was not delivered as described in the plan of care. Other deficiencies noted care provided that was not included in the plan of care.
Examples of ACHC Surveyor findings: ■ Documented visits from MSW do not match the frequency in the plan of care. ■ Catheter size changed without an order for the change.
■ Volunteer visit frequency is twice a month. There is no evidence of second visits for Sept, Oct, Nov. ■ Volunteer orders for the certification period indicated encouragement cards and cookie delivery. The records documented two volunteer visits during the period. ■ Nursing documentation indicates the patient was placed on oxygen for low oxygen saturation. There is no order for oxygen in the plan of care. ■ There is evidence of multi-discipline services provided without physician authorization of disciplines or frequency. ■ Clinical records contain no physician orders verbal/written or signed. Upon interview with multiple staff and physician, it is determined that agency uses HIPPA compliant phone app to request, receive, and authorize physician orders. There is no interface and no process to upload or input orders to EMR. ■ Patient admitted with colostomy but no related orders for nursing colostomy care.
Compliance tips for:
The plan of care must be comprehensive and specific to each discipline, including volunteers. Variations in visit frequency or care provided resulted in surveyor findings. ■ Audit plans of care and visit notes for consistency. Identify and correct issues as soon as they are noted. ■ Educate staff on the necessity to thoroughly document the care provided as ordered on the plan of care. ■ Conduct home visits with staff and audit the medical record after the visit to ensure care provided was documented correctly.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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