Volume 2024 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
Home Health Results In 2021, six standards were cited on at least 20% of surveys conducted. Of these, five repeated at that threshold in 2024, with three ( HH5-3C, HH5-6A, HH5- 11A ) at declining frequency of citation and two ( HH5- 2F, HH5-3A ) with less positive results. The general trend is promising. All of the most frequent deficiencies in this report come from the set of standards in section 5: Provision of Care and Record Management . The highest number of citations came from requirements for maintenance of a complete, current medication profile and a complete, current individualized plan of care. These are documentation issues that can be addressed with a defined process for initial and updated reviews, and more frequent auditing for accountability. The repeated standards that improved vs. 2021 for this cohort of organizations, were also related to documentation issues: providing a written description of services for the patient; responsibility for completing and authenticating clinical notes on home visits; and written information for transfer and discharge. The take-away for home health agencies: Put it in writing. All of it! Hospice Results When comparing 2024 results to those from three years earlier, we hope to see declining percentages. When we do, it’s an indication that the cohort of organizations on that survey cycle are making measurable performance improvements. Those that were cited for a deficiency were able to sustain their approved Plan of Correction. When challenging standards are cited more often, as is the case this year, we can only encourage agencies to focus on accountability. Increase the frequency of staff training; add oversight audits of documentation; pay attention to the details. Your organization and, most importantly, your patients and their families, will benefit.
ACHC was founded to accredit home-based care organizations. Our programs have expanded to include ancillary services like those provided by DME providers, pharmacies and laboratories, as well as facility-based acute care, but home is where our heart is. (Or maybe I mean to say, home is where my team’s heart is!) Despite the fact that this report focuses on deficiencies, I hope you will see it as an encouraging resource. As a whole, the noncompliance noted by ACHC Surveyors reflects problems that are easy to correct with a program of consistent training and follow up to make sure the training sticks! Home Care Results In 2021, three standards were cited on more than 20% of the surveys conducted. In 2024, only one ( HC5-3K ) reached that threshold. This is a testament to the quality ACHC-accredited home care agencies deliver. It also allows us to drop the threshold to 15% for standards included in this report. Standard HC5-3K was cited for discrepancies between the plan of care and the documented services delivered. For home based care, much of the communication between case managers and those delivering services is via the medical record. Agencies must train those writing orders to be explicit and complete, covering not just what but how required services are to be delivered. Staff in the home must be trained to follow written orders exactly, documenting their actions completely, as well as the reason for any deviation from a written order. Standards from Section 5: Provision of Care and Record Management dominate all the programs covered in this publication. Two more highlighted deficiencies ( HC5-3F, HC5-3 L) for home care agencies come from the section. The final two detailed in this report are from Section 4: Human Resources Management . HC4-6A and HC4-7A address staff competency assessment and staff training, respectively. Building compliance in these two areas of staffing will work to close the gap identified by HC5-3K .
In 2021, six standards were noncompliant on more than 20% of the surveys conducted. In 2024, all six of these were repeated and the data show declining performance. A seventh standard also reached that threshold. Standard 5-3D requires a comprehensive medication profile for each patient. This standard saw the largest three-year change in findings, moving from 25% in 2021 to 61% in 2024. Surveyors noted missing dosage instructions and parameters, missing documentation of oxygen therapy, duplicate or conflicting orders creating discrepancies for administration, failure to identify the administration site for topical medications, and unlisted medications among the deficiencies. Given the requirement to review this medication list after each IDG meeting and home visit, there are multiple opportunities to clarify and correct these problems. Hospice agencies are under scrutiny. ACHC standards align with CMS requirements and our accreditation process builds in educational opportunities to support ongoing compliance. Take advantage of the resources offered! Home Infusion Therapy Results In 2021, four standards appears as deficiencies on more than 20% of surveys. This year five standards reached that threshold. As in 2021, these frequently cited standards all come from Section 5: Provision of Care and Record Managemen t. Deficiencies for HIT5-1A and HIT5-7A have increased in frequency since 2021. Both standards were previously under 15%. HIT5-1A identifies required data for the client/patient record. HIT5-7A covers the organization’s discharge and transfer processes. In both cases, a lack of documentation was the primary issue, although surveyors did encounter some organizations without any discharge/transfer process in place. While there has been significant improvement since 86% frequency in 2021, HIT5-3C remains the most cited at a 44% rate of noncompliance in 2024. Many findings resulted from an incomplete plan of care (e.g., no safety measures, functional limitations, dose, rate, frequency, etc.). However, more concerning is the persistent lack of documentation of physician involvement. MD orders are essential to Medicare reimbursement for home infusion services.
Our findings repeatedly reflect one central issue – lack of documentation. I opened by emphasizing the need for ongoing training. Include modules on documentation as you look at your annual education plan. Case management in home-based care is removed from the patient’s location. Matching what is expected and what is delivered is largely a matter of clear, complete, written communication. All home-based care requires tight coordination among physicians, nurses, pharmacists, and unlicensed support staff. Patients and their families/ caregivers should be part of the effort, too. When all of these participants collaborate effectively, it produces the safe, high-quality, patient-centered care that ACHC accreditation champions.
Susan Mills Senior Program Director
ACHC’s Home Health , Hospice , and Home Infusion Therapy Accreditation Programs focus on the specialized services provided by Medicare-eligible licensed agencies. ACHC’s Home Care Accreditation Program is designed for agencies that offer care and supportive services that are paid by individuals, Medicaid, or private insurance. A list of Services and Distinctions recognized by ACHC for each program appears at the beginning of the section dedicated to that program’s standards.
achc.org | (855) 937-2242 | 5 achc.org | (855) 937-2242 |
4
Made with FlippingBook - PDF hosting