Volume 2024 | No. 2
SURVEYOR
HOME HEALTH
HH5-6A Overview of the requirement:
Frequency of citation:
53%
Examples of surveyor findings:
n Patient records review did not have evidence that skilled professionals assumed responsibility for preparing clinical notes. SN documented procedure but did not document if the procedure was clean or aseptic, or how the patient tolerated the procedure. ٝ MD ordered an IV for 21 days and to flush pre- and post-infusion. No evidence in SN notes of name and amount of IV infused. No evidence of flushes used. Patient was discharged from PT services. The discharge visit did not have any vital signs or assessment of the patient’s abilities compared to the admission to therapy. There is an order to assess vital signs, but no vital signs are documented on the visit note. SN visit documented “wound care per order,” without specifying the wound care or details of the procedure. n Patient records did not have evidence that skilled professionals assumed responsibility for providing services ordered by the physician in the plan of care. OT evaluation and follow-up visits were not completed as ordered. SN visit note documents nurse did not correctly follow wound care order listed in intervention. Plan of care included an order to reposition patient every two hours, but nurse did not reposition patient every two hours. n Patient records did not have evidence that skilled professionals assumed responsibility for patient and caregiver education. Plan of care intervention indicated SN to instruct patient on wound care, but documentation did not have evidence that patient was instructed on care or observed demonstrating appropriate wound care. There was no documentation of caregiver being educated on the administration of the insulin. n When auditing patient and personnel records, ensure that skilled professionals are assuming responsibility for all required tasks. Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care. Preparing clinical notes. Patient and caregiver education. Ongoing interdisciplinary assessment of the patient. Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s). Patient, caregiver, and family counseling. Communication with all physicians or allowed practitioners involved in the plan of care. Participation in the HHA’s QAPI program. Participation in HHA-sponsored in-service training.
A written policy defines the circumstances when a patient would be transferred or discharged. Transfer and discharge summaries include several elements and must be completed within required timeframes. Compliance is evaluated through review of the policies, procedures, and patient records. Processes were often found deficient because of noncompliance with deadlines. Surveyors also noted missing elements within documentation.
Comment on deficiencies:
Frequency of citation:
36%
Examples of surveyor findings:
n The patient was discharged from service with no evidence of being given a Notice of Medicare Non-coverage (NOMNC) at least 48 hours prior to dis- charge. n The NOMNC did not include the contact information for the QIO where patient can file an appeal or the patient’s insurance plan details. n Discharge summary was sent to MD outside of the five-day window. n Discharge summary does not include diagnosis, a brief description of care pro- vided, or the patient’s medical and health status at the time of discharge n Discharge summary does not include physician or allowed practitioner phone number. n There was no evidence in supporting documentation that the transfer sum- mary was sent to the receiving facility within two business days of becoming aware of transfer. n Develop and implement an effective transfer and discharge planning process. Read the requirements carefully and audit records to ensure all documenta- tion is complete. n Transfer summaries must be provided within two business days of a planned or unplanned transfer to the receiving facility. n Discharge summaries must be provided within five days of discharge to the practitioner responsible for ongoing care. n A NOMNC must be provided at least 48 hours prior to termination of home health services. The HHA furnishes skilled professional services. Individuals delivering these services must participate in the coordination of care and assume responsibility for ongoing assessment, accurate documentation, patient/caregiver education, implementation of orders outlined in the plan of care, and several additional tasks defined in the standard. Evidence of compliance is found in job descriptions, personnel files, patient records, and through direct observation. Most deficiencies indicated a failure to assume responsibility in three key areas: preparing clinical notes, providing services in the plan of care, and patient/caregiver education.
Tips for compliance:
Tips for compliance:
HH5-11A Overview of the requirement:
Comment on deficiencies:
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