top 10 certification deficiencies cited during inspections : by: compliance review services, inc, houston, tx.
1. failure of the agency to ensure care follows a written plan of care established and periodically reviewed by a md, do, or dop.
2. failure of the agency to ensure a clinical record, with pertinent past and current findings, in accordance with accepted professional standards, is maintained for every patient receiving home health services.
3. failure of the agency to ensure a poc developed, in consultation with the agency staff, covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehab potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge of referral, and any other appropriate items.
4. (tie) failure of the agency to ensure that drugs and treatments are administered by the agency staff only as ordered by the physician
5. failure of the agency to ensure that agency professional staff promptly alert the physician to any changes that suggest a need to alter the poc.
6. failure of the agency to ensure that the clinical record or minutes of case conferences establish that effective interchange, reporting, and coordination of patient care does occur.
7. failure of the agency to ensure that the comprehensive assessment includes a review of all meds the patient is currently using in order to identify any potential adverse effects or drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.
8. failure of the agency to ensure that a written summary report for each patient is sent to the attending physician at least every 60 days.
9. failure of the agency to ensure that the hha-furnished skilled nursing services, by or under the supervision of a rn, are administered in accordance with the poc.
10. failure of the agency to follow the "condition of participation of medicare". the cms requires agencies to develop, review, and implement a poc for each patient served. these poc's must detail specific treatments and assessments and must be periodically reviewed by the agency to ensure continued appropriateness of the poc. the md must be an integral part of this process, and the agency must accurately record any resulting physician orders. the total plan must be reviewed by the attending physician at least q 60 days, or more frequently, depending on the patient's condition.
Last edit by NRSKarenRN on Jan 10, '05
: Reason: font size 3
Jan 10, '05
Sadly, I have seen much of this in action. It is helpful for nurse new in the field to see this kind of info, so they know why supervisors get on their case about documentation. It also helps you to know what to document so you get it right the first time and don't get paperwork bounced back to you.
Good info, thanks for posting it!