Volume 2024 | No. 2
SURVEYOR
HOME INFUSION THERAPY
HIT5-7A Overview of the requirement:
The process for discharge/transfer of a client/patient is established by policies and procedures and reflected in the client/patient record. Surveyors review policies, procedures, and client/patient records for compliance. The primary reason for the deficiency was failure to implement a discharge/ transfer process. Providers were also found to be unaware of state-specific regulations.
Comment on deficiencies:
Frequency of citation:
24%
Examples of surveyor findings:
n There was no evidence of documentation of a discharge summary or notation in progress notes to include: 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. n A copy of the completed discharge summary was not made available to the ordering physician. n Agency did not follow their internal policy to complete a discharge/transfer summary within one week of the discharge/transfer. n Client/patient record did not contain evidence of compliance with state-specific requirements. In this case, a five-day written notification to the patient is required prior to discharging the patient from service. n Ensure discharge/transfer summary includes all required components. n Provide the documentation of discharge/transfer to the physician.
HIT5-3E Overview of the requirement:
Care/services are delivered to the client/patient as directed by the written plan of care. Compliance is evaluated through review of client/patient records. Most deficiencies resulted from incomplete documentation and discrepancies between visit notes and physician’s orders.
Comment on deficiencies:
Frequency of citation:
22%
Examples of surveyor findings:
n Patient orders included a “final normal saline flush.” There was no documentation of the normal saline flush being administered post infusion. n The patient refused an admission visit, but there was no documentation to explain the lack of the admission visit. The physician was not notified. n Nurse visits decreased in frequency, but there was no evidence of orders for new frequency. n Plan of care indicates to change Huber needle weekly. Subsequent visits did not demonstrate evidence in documentation that the needle was changed as ordered. n The staff member did not start the infusion at the correct dose for the first 25 minutes, but correct dosing was given for the remainder of the infusion. n Visit note did not include blood draw needle size, post care, or how patient tolerated procedure. n The plan of care had orders that wound care could be discontinued when the wound healed. However, there were no wound care orders. n Educate staff to consult the plan of care and document each visit thoroughly. n Educate staff to ensure that all care/treatment is documented completely with each visit. n Audit charts to ensure that all care/services are delivered in accordance with the plan of care.
Tips for compliance:
Ensure that your organization follows its own policy and/or state regulations, as the surveyor will evaluate compliance based on the more stringent requirement.
Tips for compliance:
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