Volume 2024 | No. 2
SURVEYOR
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:
achc.org | (855) 937-2242 | 17
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