Volume 2024 | No. 2
SURVEYOR
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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