SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
03 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
06 FREQUENT DEFICIENCIES IN HOME CARE AGENCIES 12 FREQUENT DEFICIENCIES IN HOME HEALTH AGENCIES
22 FREQUENT DEFICIENCIES IN HOSPICE AGENCIES
32 FREQUENT DEFICIENCIES IN HOME INFUSION THERAPY
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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Volume 2024 | No. 2
SURVEYOR
Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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Volume 2024 | No. 2
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FROM THE PROGRAM DIRECTOR
Home Health Results In 2021, six standards were cited on at least 20% of surveys conducted. Of these, five repeated at that threshold in 2024, with three ( HH5-3C, HH5-6A, HH5- 11A ) at declining frequency of citation and two ( HH5- 2F, HH5-3A ) with less positive results. The general trend is promising. All of the most frequent deficiencies in this report come from the set of standards in section 5: Provision of Care and Record Management . The highest number of citations came from requirements for maintenance of a complete, current medication profile and a complete, current individualized plan of care. These are documentation issues that can be addressed with a defined process for initial and updated reviews, and more frequent auditing for accountability. The repeated standards that improved vs. 2021 for this cohort of organizations, were also related to documentation issues: providing a written description of services for the patient; responsibility for completing and authenticating clinical notes on home visits; and written information for transfer and discharge. The take-away for home health agencies: Put it in writing. All of it! Hospice Results When comparing 2024 results to those from three years earlier, we hope to see declining percentages. When we do, it’s an indication that the cohort of organizations on that survey cycle are making measurable performance improvements. Those that were cited for a deficiency were able to sustain their approved Plan of Correction. When challenging standards are cited more often, as is the case this year, we can only encourage agencies to focus on accountability. Increase the frequency of staff training; add oversight audits of documentation; pay attention to the details. Your organization and, most importantly, your patients and their families, will benefit.
ACHC was founded to accredit home-based care organizations. Our programs have expanded to include ancillary services like those provided by DME providers, pharmacies and laboratories, as well as facility-based acute care, but home is where our heart is. (Or maybe I mean to say, home is where my team’s heart is!) Despite the fact that this report focuses on deficiencies, I hope you will see it as an encouraging resource. As a whole, the noncompliance noted by ACHC Surveyors reflects problems that are easy to correct with a program of consistent training and follow up to make sure the training sticks! Home Care Results In 2021, three standards were cited on more than 20% of the surveys conducted. In 2024, only one ( HC5-3K ) reached that threshold. This is a testament to the quality ACHC-accredited home care agencies deliver. It also allows us to drop the threshold to 15% for standards included in this report. Standard HC5-3K was cited for discrepancies between the plan of care and the documented services delivered. For home based care, much of the communication between case managers and those delivering services is via the medical record. Agencies must train those writing orders to be explicit and complete, covering not just what but how required services are to be delivered. Staff in the home must be trained to follow written orders exactly, documenting their actions completely, as well as the reason for any deviation from a written order. Standards from Section 5: Provision of Care and Record Management dominate all the programs covered in this publication. Two more highlighted deficiencies ( HC5-3F, HC5-3 L) for home care agencies come from the section. The final two detailed in this report are from Section 4: Human Resources Management . HC4-6A and HC4-7A address staff competency assessment and staff training, respectively. Building compliance in these two areas of staffing will work to close the gap identified by HC5-3K .
In 2021, six standards were noncompliant on more than 20% of the surveys conducted. In 2024, all six of these were repeated and the data show declining performance. A seventh standard also reached that threshold. Standard 5-3D requires a comprehensive medication profile for each patient. This standard saw the largest three-year change in findings, moving from 25% in 2021 to 61% in 2024. Surveyors noted missing dosage instructions and parameters, missing documentation of oxygen therapy, duplicate or conflicting orders creating discrepancies for administration, failure to identify the administration site for topical medications, and unlisted medications among the deficiencies. Given the requirement to review this medication list after each IDG meeting and home visit, there are multiple opportunities to clarify and correct these problems. Hospice agencies are under scrutiny. ACHC standards align with CMS requirements and our accreditation process builds in educational opportunities to support ongoing compliance. Take advantage of the resources offered! Home Infusion Therapy Results In 2021, four standards appears as deficiencies on more than 20% of surveys. This year five standards reached that threshold. As in 2021, these frequently cited standards all come from Section 5: Provision of Care and Record Managemen t. Deficiencies for HIT5-1A and HIT5-7A have increased in frequency since 2021. Both standards were previously under 15%. HIT5-1A identifies required data for the client/patient record. HIT5-7A covers the organization’s discharge and transfer processes. In both cases, a lack of documentation was the primary issue, although surveyors did encounter some organizations without any discharge/transfer process in place. While there has been significant improvement since 86% frequency in 2021, HIT5-3C remains the most cited at a 44% rate of noncompliance in 2024. Many findings resulted from an incomplete plan of care (e.g., no safety measures, functional limitations, dose, rate, frequency, etc.). However, more concerning is the persistent lack of documentation of physician involvement. MD orders are essential to Medicare reimbursement for home infusion services.
Our findings repeatedly reflect one central issue – lack of documentation. I opened by emphasizing the need for ongoing training. Include modules on documentation as you look at your annual education plan. Case management in home-based care is removed from the patient’s location. Matching what is expected and what is delivered is largely a matter of clear, complete, written communication. All home-based care requires tight coordination among physicians, nurses, pharmacists, and unlicensed support staff. Patients and their families/ caregivers should be part of the effort, too. When all of these participants collaborate effectively, it produces the safe, high-quality, patient-centered care that ACHC accreditation champions.
Susan Mills Senior Program Director
ACHC’s Home Health , Hospice , and Home Infusion Therapy Accreditation Programs focus on the specialized services provided by Medicare-eligible licensed agencies. ACHC’s Home Care Accreditation Program is designed for agencies that offer care and supportive services that are paid by individuals, Medicaid, or private insurance. A list of Services and Distinctions recognized by ACHC for each program appears at the beginning of the section dedicated to that program’s standards.
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HOME CARE
SECTION 4: HUMAN RESOURCE MANAGEMENT
HC4-6A
Overview of the requirement:
A Competency Assessment Program is designed and implemented for the care/ service provided by all direct care personnel.. Compliance is assessed through review of policies and procedures, patient records, personnel files, and competency assessments, as well as response to interviews. Most deficiencies were cited because the competencies were not conducted correctly, as well as for incomplete documentation in personnel files.
Comment on deficiencies:
HOME CARE SERVICES AND DISTINCTIONS Services Home Care Aide Home Care Companion Home Care Nursing Home Care Occupational Therapy Home Care Physical Therapy Home Care Social Services Home Care Speech Therapy
Frequency of citation:
18%
Examples of surveyor findings:
n Personnel records did not have evidence of a completed competency assessment: At orientation and annually t hat is specific to the job description. Performed by like disciplines. (The RN performed the PT and PTA competency.) n Competency/training of aides is not performed by or under the general supervision of a registered nurse. n Policies and procedures did not address required elements of the standard. How direct care personnel are assessed for competency. All competency assessments and training are documented. A plan is place for addressing performance and education of personnel when they do not meet competency requirements. Employee was hired/assigned and oriented to the incorrect job role of HCA and checked off on the incorrect skills n Personnel records should contain documentation of competency assessments specific to the job description. n Ensure that competency/training of aides is performed by the appropriate personnel. n Educate staff on the competency process and conduct interviews to ensure compliance.
Distinctions Palliative Care Telehealth
FREQUENT DEFICIENCIES FROM HOME CARE SURVEYS 60%
Tips for compliance:
50%
40%
30%
20%
Develop policies and procedures that incorporate all required elements, including that competency assessments must be conducted initially during orientation and annually.
10%
0%
HC4-6A
HC4-7A
HC5-3F
HC5-3K
HC5-3L
Human Resource Management
Provision of Care and Record Management
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HOME CARE
SECTION 4: HUMAN RESOURCE MANAGEMENT HC4-7A Overview of the requirement:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT
HC5-3F
The agency has a written document outlining an ongoing education plan that addresses nine required topics. Ongoing in-services must be conducted at least annually and should be specific to each classification of personnel. Compliance is assessed through staff interviews and observation, as well as review of policies, procedures, and personnel files. Most deficiencies were cited due to lack of documentation in personnel files and missing elements in the education plan itself.
Overview of the requirement:
A written plan of care is established for each client/patient accepted to nursing services. Note: This standard applies to Home Care Nursing (HCN) services only. Compliance is assessed through review of policies, procedures, and client/ patient records.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
19%
Frequency of citation:
16%
Examples of surveyor findings:
n Personnel records did not have evidence of a completed competency The plan of care did not include all required elements. No diet and nutritional needs. Missing functional limitations and safety measures. Assistive devices not completed (assessment shows walker and cane use). Allergies not listed. No measurable goals documented. n The orders did not specify dose, frequency, and route. Plan of care does not state if the IV medication is to be given using the central line tunneled catheter, it does not include to check for patency before injecting the medications, and it does not indicate to change the cap. ٝ Plan of care states “as needed,” but does not include a quantifier as to why. ٝ Medication is to be taken as needed for a specified reason, but plan of care does not include route or dose. n There was no evidence that the SN evaluation was performed as ordered. n Client/patient records did not have evidence that verbal orders are signed: With the name and credentials of the personnel receiving the order. By the physician or other licensed independent practitioner with prescriptive authority. Within the time frame established in the agency’s policies and procedures and/or state requirement. n Ensure there is a written plan of care for each client/ patient accepted to nursing services. The initial plan of care includes, but is not limited to: .Start of care date. ٝ Certification period. Client/patient demographics. Principle diagnoses and other pertinent diagnoses.
Examples of surveyor findings:
n Policies and procedures did not reflect state-specific requirements, such as: Alzheimer disease and dementia-related disorders training. HIV/AIDS education. Personnel must be informed of changes in techniques, philosophies, goals, client’s rights, and products relating to client’s care. n There was no documentation of personnel attendance at in-services or trainings. n Personnel files did not include evidence of ongoing education on the required topics.
Client/patient rights and responsibilities. How to handle grievances/complaints. Addressing communication barriers. Ethics training. The agency’s Compliance Program. Infection control training. Emergency/disaster training. Cultural diversity. Workplace (OSHA) and client safety.
Tips for compliance:
n Develop an education plan to address includes all nine required elements of the standard. n Document all training in personnel files.
Tips for compliance:
Audit state laws annually to ensure inclusion of all mandated education.
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HOME CARE
Medications: dose/frequency/route. Allergies. ٝ Orders for specific clinical services, treatments, procedures (specify
Tips for compliance:
n The plan of care must be followed and all actions documented. n Documentation needs to show: Orders are being followed. There is effective communication and coordination between all personnel on the care team. Why care was not given, including patient refusal. n Changes to the plan of care must be approved by the physician or other allowed practitioner prior to implementation. The plan of care of clients/patients receiving aide services is reviewed by an RN or other qualified professional at least every 90 days, unless state laws require more frequent reviews. Review frequency may also increase if indicated by cli- ent/patient need. Note: This standard applies to Home Care Aide (HCA) services only. Compliance is evaluated through interviews and review of client/patient records. Many deficiencies were cited when the agency was not following state law requirements. Surveyors often found that while the plan of care was present, it was missing required documentation.
amount/frequency/duration). Equipment and supply needs. Caregiver needs. Functional limitations. Diet and nutritional needs.
Safety measures. Measurable goals. Ensure that verbal orders are signed by the required parties and within the applicable timeframe. Perform client record audits to ensure compliance.
HC5-3L Overview of the requirement:
HC5-3K
Comment on deficiencies:
Overview of the requirement:
Services are delivered according to the individual client/patient plan of care
Comment on deficiencies:
Compliance is assessed through review of policies, procedures, and client/ patient records.. Most deficiencies were caused by inadequate/incomplete documentation.
Frequency of citation:
17%
Frequency of citation:
28%
Examples of surveyor findings:
n Client/patient records did not have evidence the RN or qualified profession - al reviews the plan of care at a minimum of every 90 days, unless state laws require more frequent review. n Agency was not in compliance with state-specific requirements for more stringent review timeframes. n Plan of care has order for aide services, but they are not provided. There is no evidence that MD is aware that the patient is currently not receiving aide services. n Ensure the RN or qualified professional reviews the plan of care at a minimum of every 90 days, unless state laws require more frequent review. n Documentation in the client/patient record should reflect review of specific information. n Appropriateness (care/service being provided is still needed). n Effectiveness (client/patient outcomes/response to care/service). n All needed care/services are being provided. n Change in client’s/patient’s condition. n Audit state requirements on a regular basis to ensure agency policy remains compliant.
Examples of surveyor findings:
n Order to flush the G tube with water at specified times was not completed on any of the visits. n Staff did not deliver care due to patient refusal, but the refusal was not documented. n Varying amounts of tube feed were given instead of the ordered amount three times a day. n Skilled nurse documented labs drawn and PICC dressing changed, but there was no evidence of physician orders for these tasks. n Patient was administering TPN to herself at night. There was no evidence of orders for TPN or to teach and train patient to administer. n The physical therapist did not perform initial assessment or visits as ordered. n Visit note left “musculoskeletal system” as blank. n Staff member did not document guidance with standby assist, moving, bathing and dressing, and remaining with client during meals along with encouraging patient to eat.
Tips for compliance:
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HOME CARE HOME HEALTH
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HH5-1A Overview of the requirement:
Each patient has an individual record with documentation of each home visit, treatment, or care/service. Entries are legible, clear, complete, and appropriately authenticated, dated, and timed. Signatures include the proper designation of any credentials. Compliance is assessed through review of patient records. Surveyors verify that patient records contain all required items detailed in the standard. Most deficiencies were cited due to incomplete authentication, as well as a lack of documentation of patient response and progress.
Comment on deficiencies:
HOME HEALTH SERVICES AND DISTINCTIONS Services Home Health Aide
Frequency of citation:
18%
Distinctions Behavioral Health Palliative Care Telehealth
Examples of surveyor findings:
n The visit notes did not include the credentials of the clinician. n All clinical visit notes do not contain a time with signatures.
Physical Therapy Skilled Nursing Speech Therapy
Medical Social Services Occupational Therapy
n Discharge summary was not signed by clinician. n Admission consent form signature is not legible. n The medical record contains a supervisory visit. The note is not signed by the RN. n The clinician signed all of the visits performed with a first name only, no last name or credentials. n Documentation did not have evidence of patient’s response to intervention/ teaching/treatment. n Visit notes did not have evidence of patient’s progress toward achieving goals. n Plans of care must reflect goals and the patient’s progress toward achieving them. n Maintain a complete patient record for each patient. Required elements include (but are not limited to): Comprehensive assessment. .Plans of care. Physician or allowed practitioner orders. All interventions. Identifying information. Contact information for the health care professional responsible for care/ services after discharge. Signed and dated clinical and progress notes. Discharge/transfer summaries. Copies of summaries sent to the attending physician or allowed practitioner.
FREQUENT DEFICIENCIES FROM HOME HEALTH SURVEYS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Tips for compliance:
HH5-1A
HH5-2C
HH5-2F
HH5-3A
HH5-3C
HH5-6A
HH5-11A
HH5-11F
HH7-1A
Provision of Care and Record Management
Risk Management: Infection and Safety Control
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HOME HEALTH
HH5-2F Overview of the requirement:
Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry.
A medication profile is part of the comprehensive assessment and includes ongoing review of all medications the patient is currently using. Conclusions of the medication review are documented in the patient record and used to identify any potential adverse effects and drug reactions. Compliance is evaluated through home visits, response to interviews, and review of policies, procedures, and patient records. Most deficiencies resulted from missing elements such as dose, frequency, and route. Home visits revealed discrepancies between the profile and the medications actually being taken.
HH5-2C Overview of the requirement:
Comment on deficiencies:
An individualized written plan of care is established for each patient. The care plan delineates specific care and services to be delivered based on an evaluation visit and is completed within five calendar days of the start of care. Compliance with the standard is assessed through review of policies, procedures, and patient records. Deficiencies were cited for missing elements of the comprehensive assessment, particularly patient strengths, goals, and care preferences.
Frequency of citation:
44%
Comment on deficiencies:
Examples of surveyor findings:
n During the home visit, patient indicated that medications on the medication profile were not consistent with the medications on the plan of care and what the patient/caregiver states they are taking. n Patient was to take medication sliding scale with no parameter as to when to inject the medication or how frequently. There is no evidence of sliding scale documented. n Medication profile documented by RN did not include review of any potential adverse effects, drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. n Medication profile includes an oral powder packet with no mixing instructions. n Medication profile includes topical cream with no location identified. n No route or indication given for why to take the medication. n Incomplete order does not include frequency with “as needed.” n Medication profile did not include date medications were prescribed. n Nonsterile flush is missing the following: rate of flow, amount to infuse, and insertion and discontinuing of peripheral IV for infusion. n Reeducate staff on the responsibility to review all medications the patient is currently using and that review is an ongoing part of care. n A complete medication profile includes: All current patient medications. Date prescribed or taken Medication name Dose, route, frequency Date discontinued (if applicable) Drug or food interactions n Consider regular medication profile audits to ensure accuracy and completion.
Frequency of citation:
15%
Examples of surveyor findings:
n There is no evidence that the patient’s strengths and care preferences were included in the plan of care. n Patient records did not have evidence that the comprehensive assessment was completed no later than five calendar days after the start of care. n Patient did not have a skilled need other than “teach and educate” from admission and was recertified three times for the same need, with the same goals and interventions. n Patient records did not have evidence that when physical therapy was the only service ordered by the physician, a physical therapist completed the comprehensive assessment. n The comprehensive assessment did not include the patient’s current health, psychosocial, functional, and cognitive status. n There is no evidence that the comprehensive assessment includes the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. n Educate staff on the required components of the standard and how to recognize when the patient record is missing information. n Ensure that the comprehensive assessment demonstrates the patient’s continuing need and eligibility for skilled home health services.
Tips for compliance:
Tips for compliance:
Incorporate the use of the current version of the Outcomes and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items into comprehensive assessments.
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HOME HEALTH
HH5-3A Overview of the requirement:
HH5-3C Overview of the requirement:
Each patient has an individualized plan of care developed in consultation with the patient, physician (or allowed practitioner), and agency staff. The plan meets the needs identified in the comprehensive assessment and includes measurable outcomes. Compliance is evaluated through review of policies, procedures, and patient records. The plan of care requires consistent communication between multi- ple disciplines. Most deficiencies resulted from a lack of cohesiveness between physician/practitioner orders and actions taken. Surveyors also noted repeated absence of stated goals and incomplete medication instructions.
The agency provides the patient and caregiver with written documentation of the care to be provided. Compliance is evaluated through review of documentation in patient records. Deficiencies were most often cited due to missing details, such as clinical manager contact information and instructions for a home exercise program.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
20%
Examples of surveyor findings:
n During home visits, patients did not have evidence that they had been provid- ed the name and contact information of the clinical manager. n There is no documentation in the patient record that written wound care and wound vac instructions were provided. n There was no evidence the agency provided the patient and caregiver a copy of written instruction outlining physical therapy treatment, or home exercise program. n Patient records did not have evidence that the HHA provided the patient and caregiver with written instructions outlining medication name, dosage and frequency. n During home visit it was observed that a written medication list contained medical abbreviations in dosing instructions. n There was no documented evidence within this clinical record that the patient had been provided written instruction regarding their planned SN and PT visit frequency. n The patient and caregiver must be given written instructions outlining: Medication name, dosage and frequency, and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA The name and contact information of the HHA clinical manager. Treatments, including therapy services, under the purview of the HHA. Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. n Educate staff and conduct regular audits to ensure understanding that all required details must be included.
Frequency of citation:
56%
Examples of surveyor findings:
n There is no documentation that the physician was notified to verbally approve the physical therapy plan of care. n There is a discipline and frequency for PT, but there are no therapy orders and goals. n The agency did not have an approved and signed plan of treatment within 30 working days, per state-specific regulations. n Plan of care indicates, “Home Health Aide to provide assistance with personal care and ADLs,” with no visit frequency. n Referral order includes nursing, PT, OT, ST, MSW and aide. No evidence in doc- umentation that need for ST, MSW or Aide was assessed as ordered. There was no supporting documentation as to why disciplines were omitted. n Plan of care did not include DME & supplies. n Intervention section did not have evidence of teaching/treatment to address the underlying risk factors to reduce or prevent hospitalization and emergency room visits. n There is no evidence in the patient chart that the physician was contacted to approve home health orders after the start of care. n Compare state and federal regulations and adhere to the most stringent requirement. n Include measurable outcomes and goals identified by the HHA and the patient. n Medication lists must include dose, frequency, and route. The home health agency is responsible for obtaining orders prior to start of care. . The plan of care must be consistent with practitioner orders. .If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, consult the physician/practitioner to approve additions or modifications to the original plan.
Tips for compliance:
Tips for compliance:
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HOME HEALTH
HH5-6A Overview of the requirement:
Frequency of citation:
53%
Examples of surveyor findings:
n Patient records review did not have evidence that skilled professionals assumed responsibility for preparing clinical notes. SN documented procedure but did not document if the procedure was clean or aseptic, or how the patient tolerated the procedure. ٝ MD ordered an IV for 21 days and to flush pre- and post-infusion. No evidence in SN notes of name and amount of IV infused. No evidence of flushes used. Patient was discharged from PT services. The discharge visit did not have any vital signs or assessment of the patient’s abilities compared to the admission to therapy. There is an order to assess vital signs, but no vital signs are documented on the visit note. SN visit documented “wound care per order,” without specifying the wound care or details of the procedure. n Patient records did not have evidence that skilled professionals assumed responsibility for providing services ordered by the physician in the plan of care. OT evaluation and follow-up visits were not completed as ordered. SN visit note documents nurse did not correctly follow wound care order listed in intervention. Plan of care included an order to reposition patient every two hours, but nurse did not reposition patient every two hours. n Patient records did not have evidence that skilled professionals assumed responsibility for patient and caregiver education. Plan of care intervention indicated SN to instruct patient on wound care, but documentation did not have evidence that patient was instructed on care or observed demonstrating appropriate wound care. There was no documentation of caregiver being educated on the administration of the insulin. n When auditing patient and personnel records, ensure that skilled professionals are assuming responsibility for all required tasks. Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care. Preparing clinical notes. Patient and caregiver education. Ongoing interdisciplinary assessment of the patient. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s). Patient, caregiver, and family counseling. Communication with all physicians or allowed practitioners involved in the plan of care. Participation in the HHA’s QAPI program. Participation in HHA-sponsored in-service training.
A written policy defines the circumstances when a patient would be transferred or discharged. Transfer and discharge summaries include several elements and must be completed within required timeframes. Compliance is evaluated through review of the policies, procedures, and patient records. Processes were often found deficient because of noncompliance with deadlines. Surveyors also noted missing elements within documentation.
Comment on deficiencies:
Frequency of citation:
36%
Examples of surveyor findings:
n The patient was discharged from service with no evidence of being given a Notice of Medicare Non-coverage (NOMNC) at least 48 hours prior to dis- charge. n The NOMNC did not include the contact information for the QIO where patient can file an appeal or the patient’s insurance plan details. n Discharge summary was sent to MD outside of the five-day window. n Discharge summary does not include diagnosis, a brief description of care pro- vided, or the patient’s medical and health status at the time of discharge n Discharge summary does not include physician or allowed practitioner phone number. n There was no evidence in supporting documentation that the transfer sum- mary was sent to the receiving facility within two business days of becoming aware of transfer. n Develop and implement an effective transfer and discharge planning process. Read the requirements carefully and audit records to ensure all documenta- tion is complete. n Transfer summaries must be provided within two business days of a planned or unplanned transfer to the receiving facility. n Discharge summaries must be provided within five days of discharge to the practitioner responsible for ongoing care. n A NOMNC must be provided at least 48 hours prior to termination of home health services. The HHA furnishes skilled professional services. Individuals delivering these services must participate in the coordination of care and assume responsibility for ongoing assessment, accurate documentation, patient/caregiver education, implementation of orders outlined in the plan of care, and several additional tasks defined in the standard. Evidence of compliance is found in job descriptions, personnel files, patient records, and through direct observation. Most deficiencies indicated a failure to assume responsibility in three key areas: preparing clinical notes, providing services in the plan of care, and patient/caregiver education.
Tips for compliance:
Tips for compliance:
HH5-11A Overview of the requirement:
Comment on deficiencies:
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Volume 2024 | No. 2
SURVEYOR
HOME HEALTH
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL HH7-1A Overview of the requirement: HHA risk management policies address infection prevention and control. Comment on deficiencies: Evidence of compliance includes interview responses, review of policies, procedures, and patient records, and direct observations of care. Almost all deficiencies were cited during home visits and reflected improper hand hygiene. Surveyors also observed faulty equipment bag processes.
HH5-11F Overview of the requirement:
The duties of the home health aide are prepared by an RN or other appropriate skilled professional and implemented appropriately. Compliance is assessed through review of patient records and direct observation. Most deficiencies reflect a gap between the task list and the documentation of services provided. Task frequency was often missing.
Comment on deficiencies:
Frequency of citation:
15%
Examples of surveyor findings:
n During the home visit, the surveyor observed the aide administering medications through the g-tube and performs finger stick. The tasks performed by the aide are out of the scope of the aide and were not ordered to be provided. n Personnel records review did not have evidence that home health aide met the qualifications defined by Medicare’s Conditions of Participation. n Aide visit note did not have evidence that tasks were performed as ordered. n Aide care plan assigned task frequency “as needed,” but lacked specific statement that patient is cognitively and functionally able to make decisions: n Aide care plan denotes assisting with wheelchair while notes have assistance with walker documented. n Aide plan of care did not indicate the frequency for each task assigned. n The aide care plan didn’t contain vital sign parameters on when to contact the nurse. No information provided on when to notify the nurse of abnormal findings. n Aide care plan is incomplete and not signed by RN. n If the aide plan of care does not indicate frequency of tasks, it is incomplete. n Aides may only provide services that are ordered, included in their role- specific plan of care, permitted under state law, and consistent with their training. n “Per patient choice” can be used for tasks only if the RN assesses and determines that the patient is cognitively and functionally able to make the decision. PRN cannot be used. Home health aides are collaborative members of the interdisciplinary team. They provide hands-on care, update records, and communicate with other providers. Set these team members up for success. Provide in- depth training and competencies. Identify gaps in understanding. Offer additional education and support.
Frequency of citation:
21%
Examples of surveyor findings:
n RN conducting skilled visit did not cleanse hands prior to patient care. n During home visit, RN placed bag down without barrier between surface and home care visit bag and without cleaning surface prior to placing bag on surface. n Bag was open before and during visit with items spilling out of top. No evidence that HHA follows accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. n LVN went in and out of bag multiple times without hand sanitizing each time. n Nurse did not change gloves or perform hand hygiene after removing soiled dressing and before applying new dressing. n Nurse washed hands at patient’s bathroom sink using patient’s soap which was not antibacterial, then dried hands with the patient’s cloth hand towel n Nurse cleansed equipment with Lysol wipes and immediately placed them back into bag without allowing the required kill time. n Enforce accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. n Dev elop specific policies for hand hygiene and bag technique. Observe home visits periodically to assess compliance. n Educate staff on appropriate equipment cleaning procedures and disinfectant wait times.
Tips for compliance:
Tips for compliance:
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Volume 2024 | No. 2
SURVEYOR
HOSPICE
SECTION 4: HUMAN RESOURCE MANAGEMENT HSP4-13A Overview of the requirement:
Hospice aides are assigned to patients by a registered nurse, who prepares written care instructions to be followed by the aide. The aide and RN communicate and collaborate to update the plan of care when needed. Evidence of compliance is assessed through review of patient records and direct observations of care. Many deficiencies were cited because the number of aide visits did not match the frequency stated in written orders. Additional findings related to insufficient documentation in the patient record.
Comment on deficiencies:
Frequency of citation:
56%
Services Hospice Care Hospice Inpatient Care HOSPICE SERVICES AND DISTINCTIONS Distinctions Age-Friendly Care Palliative Care Telehealth
Examples of surveyor findings:
n The aide visit frequency was ordered twice weekly. The record indicated only one visit per week. n The aide written instructions indicated to provide a shower each visit. At the observation visit, the aide indicated he would provide a bed bath and had been doing a bed bath for five months. n Aide written instructions included “as directed” as frequency under change linen, assist with bedside commode, and oral care. n No evidence of collaboration between aide and RN. Aide written instructions state to assist with ambulation with walker and assist to bathroom. RN comprehensive assessment indicated that patient is non ambulatory and needs to use wheelchair. n The aide written instructions do not include oxygen precautions, fall precautions, or skin breakdown precautions which were identified safety measures and applicable to the plan of care. n Though the DPCS was able to provide a verbal explanation that visits were refused by the family on an ongoing basis, and this is why aide services were ultimately discontinued, there was no evidence or documentation in the EMR related to the missed visits. n Numerous notations by the aide indicated that the task was not completed “per patient preference.” There was no documentation that the patient was functionally and cognitively able to make the decision. n Documentation in patient records should reflect that hospice aides provide services that are: Ordered by the interdisciplinary group. Included in the plan of care. Permitted to be performed under state law by such hospice aide. Consistent with the hospice aide training.
FREQUENT DEFICIENCIES IN HOSPICE AGENCIES
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Tips for compliance:
HSP4-13A
HSP5-1A
HSP5-3C
HSP5-3D
HSP5-4A
HSP5-4B
HSP5-4F
Human Resources Management
Provision of Care and Record Management
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Volume 2024 | No. 2
SURVEYOR
HOSPICE
n Educate staff on proper visit documentation, including the use of “PRN” or “per patient choice.” Whether for personal or nonpersonal care tasks, the use of these terms is unacceptable, unless the RN has documented that the patient is cognitively and functionally able to make the decision n Observe and assess aide visits to ensure consistency between tasks and orders. n Audit patient records and work with the RN to update plans of care when needed.
n Election of benefit did not contain start of care date. n On admission the patient was documented as 80 years old. The patient was 83 years old on admission. n Implement regular audits to confirm the patient record reflects the most recent, accurate information. n Review election statements to ensure all items are present and completed correctly. Educate all members of the Interdisciplinary team on the required elements of the standard for information entered into the patient record: Include signatures, credentials and dates. Check and recheck entries for accuracy. Correct typos and use clear language. Avoid abbreviations that are not generally understood and/or approved by the agency. 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 spiritual needs are evaluated. Evidence of compliance is based on review of patient records. While deficiencies were sometimes cited due to lack of psychosocial assessments, the vast majority of findings were related to spiritual and bereavement components.
Tips for compliance:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HSP5-1A Overview of the requirement:
A patient record is maintained for each individual who receives care. All entries are legible, clear, complete, appropriately authenticated, and dated. The patient record documents home visits, treatments, and all care/services provided. Evidence of compliance is evaluated through review of patient records and response to interviews. Many deficiencies related to errors in documentation, specifically incomplete authentication (missing signatures and credentials).
Comment on deficiencies:
HSP5-3C Overview of the requirement:
Frequency of citation:
51%
Examples of surveyor findings:
n The nursing notes do not contain evidence that they are appropriately authenticated and dated within the currently accepted standards of practice. n The Consent for Hospice Care listed the MD name but had no NPI or telephone number. n Visit notes do not include credentials as part of the electronic signature. n The advanced directive is not on record. n The documentation does not use agency-approved abbreviations. n Consent lists all disciplines with checkbox for disciplines patient accepts. All options are left blank. n The physician’s certification, SN initial comprehensive assessment, and visit notes indicate the patient’s primary terminal diagnosis is congestive heart failure. The initial plan of care indicates the patient’s primary terminal diagnosis is cancer of the stomach. n The documentation is not specific for the wound assessment/description and the actual dressing changes performed. n The nurse documented providing instruction for breathing treatments. Upon interview, the documentation is incomplete as the patient did not have a working machine at the time of the visit. The hospice ordered a replacement nebulizer which was not documented. n Visit date, MD name, and RN CM name listed on missed visit note. No evidence that any of the remaining questions were answered or documentation as to the reason for missing the visit.
Comment on deficiencies:
Frequency of citation:
46%
Examples of surveyor findings:
n Patient records did reflect that the comprehensive assessment was completed no later than five calendar days after the election of hospice care. n The comprehensive initial assessment did not identify the psychosocial needs of the patient/family. n Patient records do not contain all social components: communication strengths and barriers, response to previous loss, literacy and language skills. n Clinical record did not show evidence that bereavement assessment was completed within five days of admission. n Bereavement assessment documented first name and phone number with no evidence of address. Relationship was not completed.
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