Top 3 Home Health Deficiencies for ACHC Customers

Aug 30, 2013 1:59:09 PM / by ACHC

Top 3 Home Health Deficiencies for ACHC Customers

By Julie Pazun

We are often asked about the most commonly cited areas on a home health survey. Below are the top 3 cited areas and some tips on how to ensure that your agency will be in compliance during the on-site survey.

HH5-2 F There is a comprehensive assessment that includes a review of all medications the patient is currently taking (prescription and non-prescription). The organization performs a drug regimen review.

This ACHC standard is linked to the CMS Conditions of Participation 484.55. Organizations often are deficient in this area because the clinician does not ensure that the medication profile is updated or there is no evidence that the drug regimen review has occurred. Often times, surveyors will find documentation of new medications in the clinical notes, but the nurse has not updated the medication list.  In order to ensure compliance, the organization should confirm the staff is asking at each patient visit if there have been any changes to their medications and also request to see the medication bottles during the visit.

HH 5-11F The agency defines the duties of the home health aide and ensures that they are implemented in patient care.

This ACHC standard is linked to the CMS Condition of Participation 484.36. Deficiencies are sited here when the care provided by the aide deviates from the written plan of care.  Organizations should ensure that their aides are properly in-serviced to perform the tasks as outlined on the aide plan of care. If these tasks are not able to be performed as ordered, there should be evidence in the record that the aide has contacted the case manager for revision of the plan of care. The supervising nurse should be evaluating the aide care plan during the aide supervisory visits to ensure that the tasks ordered still meet the needs of the patient. The aide care plan should be updated as the patient’s needs change.

HH5-8B The agency’s personnel promptly alert the physician to any changes that suggest a need to alter the plan of care.

This ACHC standard is linked to the CMS Conditions of Participation 484.18. Deficiencies are sited here when there is evidence in the clinical record that assessment findings fall outside the norm for the patient or progression towards the expected outcome for the patient. This could include elevated vital signs, abnormal lab results, deteriorating wound conditions or deteriorating physical/mental conditions in which the patient would benefit from a change in the plan of care, including additional services.

For more information on this topic, contact your Accreditation Advisor at (855) 937-2242.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

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About the Author:

Julie Pazun ThumnailJulie Pazun has been a Registered Nurse for over 20 years, working in both acute care as well as community settings. She is responsible for the development and implementation of the Home Health, Hospice, Private Duty, Behavioral Health and Convenient Care Clinic Accreditation Programs. In 2009, Julie began her career with ACHC as a Surveyor and joined the management team in 2011.

Topics: Accreditation, ACHC, Deficiencies, Home Health


Written by ACHC

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