Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
Hospice Results Like findings for home health agencies, hospice deficiencies are generally consistent and clustered in section 5: Provision of Care and Record Management . This year, seven standards were cited on more than 20% of the surveys performed and all but one came from this section. Year over year, HSP5-4A is the most frequently cited. It addresses the requirement for an individualized, written plan of care designed to manage the scope of issues identified on the initial, comprehensive, and updated comprehensive assessments. The plan is interdisciplinary, and developed collaboratively with the care team, the attending physician, and the patient or representative. It requires a level of detail adequate to direct all care and services. It is reviewed regularly for alignment with the medication profile, care orders, and therapies and services delivered. It is closely related to other standards identified in this report, which can create a cascade of deficiencies. ACHC focuses on providing education needed to bridge gaps in compliance. Webinars and training support compliance throughout the accreditation cycle and the onsite survey is an opportunity to ask clarifying questions to unblock full understanding of the standards. Home Infusion Therapy Results This year, we focus on standards that were cited for non-compliance on at least 20% of the surveys performed. Three years ago, when this cohort of providers was last surveyed, three standards were noted as deficient on more than 20% of the surveys. This year, three standards again reached that frequency, but a new standard emerged as the most challenging. HIT5-1A was cited on 43% of surveys. The standard requires that the organization's policy for client/ patient records include specific items. Findings did not identify missing or inadequate policies.
A survey with no findings—no identification of non-compliance—is exceedingly rare and that knowledge can be daunting. The important takeaway when exploring deficiency data is growth and improvement. This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for four individual ACHC accreditation programs: Home Care, Home Health, Hospice, and Home Infusion Therapy. This year’s data span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
Instead, ACHC Surveyors noted that policies were not adequately implemented. Documentation did not include the detail needed to support excellent patient care. There's much better news for HIT5-3C which was a finding on 71% of surveys in 2022 and for only 26% this year. This requirement for the plan of care includes specific data points but previous deficiencies focused on the absence of a physician signature. This year, very few plans of care lacked evidence of physician oversight but some were missing other required elements. Standard HIT5-8B was noted on 21% of surveys. The standard which focuses on regular review of patient medications by a licensed, skilled professional, improved for this cohort of providers by 12.5% over 2022 results. Summary The common theme across these four programs is the need for improvement in documentation. A complete and accurate written record tells the story of each patient's care. This is essential to continuity and coordination across handoffs. Many of these rely on the written record in home based care where team members may have fewer opportunities to interact face to face. Promote staff training and frequent audits of patient records for completeness and consistency. These are avoidable deficiencies! Reach out to ACHC for additional guidance If you find persistent sticking points. We're here to help you do better — for your patients and your agency!
Home Care Results Six standards were cited as non-compliant on more than 15% of the surveys covered by this report. HC5- 3K remains the most consistently challenging for agencies. It was cited on 40% of surveys, a decline in performance from last year, but an improvement for the organizations in this triennial cohort that were previously surveyed in 2022. Three years ago, it was cited on 52% of surveys. Each of the six home care standards on the pages that follow requires documentation of actions and effective team communication. Standard HC2-4B concerns the client’s right to file a complaint, Standard HC4-2C requires proper TB testing and evidence of an annual risk assessment; and the four standards from Section 5: Provision of Care and Record Management , all refer to information that should be present in the client/ patient record. Agencies that implement effective training for documentation practices will be in good stead for their next accreditation survey. Keep it concise but explicit and complete, record what and how required services are to be delivered.
Home Health Results In home health agencies, frequent deficiencies tend to be consistent year over year. This is because many of the standards, especially those in Section 5: Provision of Care and Record Management , have a large number of individual elements that require specific evidence of compliance. For an individual agency, the scope and nature of the deficiencies on the Summary of Findings gives context for the most common deficiencies. For example, are your agency’s deficiencies consistent across a majority of patient or personnel records? This would indicate a systemic problem that could be the focus of a performance improvement project. Is the non-compliance related to a particular discipline or even to patients assigned to an individual clinician? This would indicate a need for focused training on documentation requirements. Finally, are documentation errors isolated? This can be corrected with additional oversight and spot audits. From a high-level perspective, the good news is that a comparison of this year’s results with those from 2022 when this same cohort of agencies was last surveyed shows consistent improvement. The aggregated average frequency of the top eight standards in 2022 was 41%. This year, that average dropped to 32%. Every individual standard noted in this year’s report showed improvement from three years ago with the exception of HH5-1A which held steady as a deficiency finding for 22% of the organizations surveyed.
Susan Mills Senior Program Director
achc.org | (855) 937-2242 | 5
4
Made with FlippingBook - Share PDF online