Volume 2024 | No. 2
SURVEYOR
HOME INFUSION THERAPY
n Signed:
n Verbal orders were not documented and signed with the name and credentials of the personnel receiving the order and signed by the physician within the time frame established in the organization’s policies and procedures and/or state requirement. n Plan of care did not include order for IV medication type, amount or duration. n The patient receives IVIG therapy. The order for IVIG administration did not include the infusion rate. n Plan of care did not state whether method of delivery is pump or gravity. n The order does not include a frequency for when a dressing change would need to be performed. n The plan of care sections for diet and functional limitations were both left blank. n Order does not include steps for cleaning agent, bio patch, dressing etc. n There were no safety measures on the plan of treatment to address bleeding precautions. n Order did not include the type of antiseptic solution used when prepping the skin to insert a peripheral I.V. n Plan of care does not include orders for infusion access site either via PICC, central line, or peripheral access. n The plan of care did not include written goals and expected outcomes. n The plan of care states medication is to be taken “twice per day,” however both the referral and pharmacy order are for every 12 hours. n Every plan of care must be established by a physician and prescribe the type, amount, and duration of the home infusion therapy services that are to be furnished. n Medication administration orders should include the medication and flushes to be administered, dose, route, frequency, and delivery method, n Document verbal orders with the name, credentials, and signature of the personnel receiving the order. Ensure the order is signed by the physician. Complete this task within required timeframes. n Review medication lists and confirm documentation of dose, frequency, and route.
Release of information and other documents for Protected Health Information (PHI). Notice of receipt of Client/Patient Rights and Responsibilities statement.
n Source of referral. n Diagnosis. n Admission and informed consent documents. n Physician’s orders appropriate to the level of care/service. n Plan of care – initial and updated. n Client/patient response to care/service provided. n Signed and dated clinical and progress notes. n Assessments: Initial. Ongoing, if applicable. Home, if applicable. n If applicable:
Evidence of coordination of care/service provided by the organization with others who may be providing care/service. Copies of summary reports sent to physicians. A discharge summary. Admission and discharge dates from a hospital or other institution. Advance directives, if applicable. There is a written plan of care established by a physician for each patient prescribed home infusion therapy services. The initial plan of care addresses 13 specific data points. Compliance is assessed through review of policies, procedures, and client/ patient records. Most deficiencies cited plans of care that did not involve a physician, as well as incomplete data.
Tips for compliance:
HIT5-3C Overview of the requirement:
Comment on deficiencies:
Frequency of citation:
44%
Examples of surveyor findings:
n There was no evidence of physician involvement with the plan of care.
Do not leave sections blank on the plan of care. Update with “not applicable” and/or the reason why there is no answer.
The agency did not send plan of treatments to the physician for approval and signature. No evidence that a plan of care was established by a physician that prescribes the type, amount, and duration of the home infusion therapy services that are to be furnished.
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