Volume 2024 | No. 2
SURVEYOR
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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