Volume 2024 | No. 2
SURVEYOR
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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