Home care agencies are often cited during an accreditation survey for care and services not being delivered in accordance with the client’s/patient’s plan of care, according to the latest The Surveyor newsletter published by Accreditation Commission for Health Care (ACHC).

The Quality Review edition found that ACHC Standard HC5-3K was the most frequently cited deficiency for Home Care Accreditation, with 52% of those surveyed not meeting standard requirements.

Standard HC5-3K: Care/services are delivered in accordance with the written plan of care.

The expectation is that every client/patient record provides documentation that the care and services being delivered are in accordance with the client/patient plan of care and are directed at achieving established goals.

Client/patient record documentation also should detail effective communication and coordination between all personnel involved in the client’s/patient’s care.

What’s Being Missed?

This common deficiency often stems from either incomplete documentation in the client/patient record or from direct care clinicians making entries in the medical record that do not support that appropriate care was provided.

Survey Findings Example

The following example illustrates what a Surveyor may write about incomplete medical record documentation:

“Skilled nursing clinical note does not have documentation that the patient’s wound was assessed or instruction on wound care was provided to the patient as ordered. In addition, the skilled nurse (SN) documented administering an enoxaparin sodium injection. There was no detailed documentation of the site or dosage of the administration.”

Tips for Compliance

• Ensure all care provided is clearly and accurately documented in the client/patient record.
• Ensure documentation supports the reason for any deviation from the plan of care and the ordering practitioner is notified, as applicable.
• Ensure any client/patient refusal of service is properly documented as a client/patient refusal.
• Perform routine audits of client/patient records to certify that all care being provided, such as treatments, interventions, and tasks, is documented accurately, completely, and in accordance the plan of care.

Here for You

ACHC is your partner in accreditation. For more information, contact your Account Advisor, email [email protected], or call (855) 937-2242, ext. 457.