Volume 2024 | No. 2
SURVEYOR
HOME INFUSION THERAPY
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT HIT5-1A Overview of the requirement:
Policies and procedures require the client/patient record to contain specific data points, and an accurate record is maintained for each patient. Compliance is assessed through review of policies, procedures, and client/ patient records. Surveyors often cited incomplete documentation and missing data.
Comment on deficiencies:
Frequency of citation:
29%
Examples of surveyor findings:
n Records did not have evidence of an initial home assessment. n When patients were seen by the SN for blood draws, there was no indication of the patient’s response to the procedure. n The certification period was > 60 days and the plan of care was not reviewed or updated. n There was no documentation for client/patient response to dressing changes and port access. n Agency was unable to locate admission forms which contained signed release of information and other documents for protected health information (PHI), admission and informed consent documents, and signed notice of receipt of patient rights statement. n The patient has a vascular access device. The physician order does not include the technique for access, or cleansing agent required for VAD access. n Initial assessment of PICC line did not include the external length or arm circumference. n Patient did not have a documented designated emergency contact. n Patient as discharged to the hospital. There was no discharge summary documented and sent to the doctor. Conduct regular chart audits to ensure that documentation in the client/patient record included (at a minimum): n Identification data.
Services Home Infusion Therapy Supplier HOME INFUSION THERAPY ACCREDITATION
FREQUENT DEFICIENCIES IN HOME INFUSION THERAPY
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Tips for compliance:
n Names:
Family/legal guardian/emergency contact. Primary caregiver(s) . Physician responsible for care.
HIT5-1A
HIT5-3C
HIT5-3E
HIT5-7A
HIT5-8B
Provision of Care and Record Management
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