Volume 2025 | No. 2
SURVEYOR
HOME INFUSION THERAPY
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HIT5-1A Frequency of the citation: 43%
Overview of the requirement: Policies and procedures define the required content of each client/patient record.
Comment on deficiencies: Compliance is assessed through review of policies, procedures, and client/patient records. Surveyors cited policy implementation concerns when data was missing from the records. Examples of ACHC Surveyor findings: ■ Release of information, informed consent, and notice of client/patient rights and responsibilities were unsigned in patient records. ■ Client/patient records did not document the response to care provided. ■ Skilled nurse visit notes were inconsistent in documenting patient tolerance of PICC dressing change and medication infusion. ■ The medical record identified the patient code status as DNR but there was no corresponding advance directive in the chart. ■ No patient emergency contact noted.
Services Home Infusion Therapy Supplier HOME INFUSION THERAPY ACCREDITATION
FREQUENT DEFICIENCIES IN HOME INFUSION THERAPY
Compliance tips for:
The standard identifies 22 items that must be included in the client/patient record, at minimum. Specifically:
60%
Nerd Newbies (understand the requirement)
50%
■ Identification data. ■ Names:
40%
ٝ Family/legal guardian/emergency contact. ٝ Primary caregiver(s). ٝ Source of referral. ٝ Physician responsible for care.
30%
20%
■ Signed and dated:
ٝ Admission and informed consent documents. ٝ Release of information and other documents for Protected Health Information (PHI).
10%
0%
HIT5-1A
HIT5-3C
HIT5-8B
Provision of Care and Record Management
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