Volume 2024 | No. 2
SURVEYOR
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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