Volume 2025 | No. 2
SURVEYOR
PHARMACY
DR X5-2C Applicable services: Ambulatory Infusion, Infusion Nursing, Infusion Pharmacy with or without Sterile Compounding, Specialty Pharmacy with or without DME
Compliance tips for:
■ The written plan of care must contain several elements. The standard provides a comprehensive list. Examples include: ٝ Start of care date. ٝ Demographics. ٝ Principle and additional diagnoses. ٝ Medications and allergies. ٝ Interventions and monitoring. ٝ Expected outcomes/goals. ■ The plan of care is driven towards positive client/patient outcomes, so the inclusion of expected outcomes/goals is crucial. How can an effective path be defined without a goal? ■ If the patient declines additional counseling, goals should still be established and communicated. ■ No two care plans should look exactly the same. ■ Develop and implement care plan templates that address all the requirements and will ensure the care plan will be patient-specific. ■ Create a plan of care checklist to facilitate auditing client/patient medical records for complete and accurate information (e.g., ensuring that problems, interventions, and goals are not for a medication discontinued a while ago). ■ Investigate whether software can flag empty fields and prevent personnel from moving forward without completion. ■ Establish a monitoring plan to track progress towards achieving the expected client/patient outcomes. ■ Review processes with staff to ensure that all patients have a documented goal of therapy. Audit compliance with care plan requirements as part of client/patient record reviews and incorporate the findings into the PI program. ■ Provide education on disease management and care planning to patients/ caregivers.
Nerd Newbies (understand the requirement)
Frequency of the citation: 18%
Overview of the requirement: There is a written plan of care for each client/patient accepted for care/services. Care planning is directed toward driving positive client/patient outcomes. Comment on deficiencies: Surveyors review client/patient records, policies, and procedures to evaluate compliance. While surveyors sometimes noted there was no care plan in place, most deficiencies were cited due to missing elements within the care plan. Client/patient records often lacked documentation of therapy goals/outcomes at the start of care. Other deficiencies related to medication profiles, interventions, and monitoring. Examples of ACHC Surveyor findings: ■ Client/patient records failed to show evidence of a written plan of care. ■ Client/patient records were lacking documentation of expected client/patient outcomes/goals at start of care. ■ The goals, problems, interventions, and monitoring plans were not disease state or drug-specific. The organization uses a template that is not customized to address individual patient needs. ■ Client/patient records did not have medications provided from external pharmacies included on the medication profile list. The medication profile needs to include the dose, frequency, and route for all medications (OTCs, herbals, Rx, etc.).
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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