Survey time is always stressful for home care agencies. You and your staff work every day to provide quality care and monitoring, but it does not mean something won’t slip through the cracks.
Below are the items listed by CHAP as most-cited deficiencies (in bold) during the previous year and some tips I’ve seen that can help avoid these situations:
Top 10 CHAP Home Care Deficiencies for 2021
1. HCPC.9 Staff provide personal care services per the current service plan. Tips: Educate aides to follow the Aide care plan assignment. Reinforce that the Aide must notify the Supervisor or assigned responsible staff member prior to making any changes. Ensure the responsible staff member is revising the plan in real-time, as changes occur. Audit to ensure compliance.
2. HCMG.8 Staff personnel records include evidence of meeting the qualifications of their job description and competency and evaluation per organizational policy and procedure. Tips: Ensure hiring and ongoing personnel checklists are up to date. Utilize tracking systems to ensure compliance. Audit personnel files quarterly. Ensure aide competency and supervisory visits are compliant.
3. HCIC.3 It is required that staff have access to PPE and use standard precautions appropriate to: The client, care/service provided, CDC and the state or county health department. Tips: Ensure ongoing training on revisions by CDC, public health, etc. Don’t assume staff know about changes or will read an email you send out. Review competencies for handwashing, bag technique, donning and doffing PPE, etc. either through in-person training or via Zoom. As a leader, you should supervise some home visits to ensure compliant infection control techniques. Audit for compliance.
4. HCPC.5 It is required that policy and procedure defines minimum plan content, to include: how often services are provided. Service plan policy and procedure complies with applicable law and regulation. Tips: Ensure your policies state that your Aide Care Plan includes how often services are provided based on the needs of the patient. Educate aides that they must follow the frequency that is included in the plan. Audit for compliance.
5. HCPS.7 It is required that professional care services provided are consistent with the client’s plan of care and orders of a physician or other licensed practitioner and state law. Tips: Ensure all staff clearly understand that care requires a physician order and nothing can be done without a physician order. Educate clinicians on following physician orders and updating as those orders change. Audit visits for compliance.
6. HCIC.4 There is a TB control plan that requires staff be screened/tested per local/state law or per policy. In the absence of Organization-defined risk or local or state law, the Organization screens/tests staff per current CDC guidelines. Tips: Ensure all current local or state law or regulations and CDC guidelines are known by everyone in the agency. Ensure your policy is current to regulations. Audit regularly to ensure that your policy is being followed.
7. HCCC.1 The Organization has a Client Bill of Rights addressing the following: The client has the right to: Receive information about the scope of care/services the Organization provides and any limitations on those services; Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse or exploitation, and the misappropriation of client property by anyone furnishing services on behalf of the Organization; Refuse care/service. Tips: Ensure your policy has all items addressed in the standard. Ensure all client rights and responsibility forms and documentation complies with the CHAP policy. Educate clinicians that all items must be communicated to the patient and/or caregiver where applicable, and documented as a standard part of their visit protocol.
8. HCPC.15 It is required that policy defines the process to end personal care services, whether if client-requested or Organization-initiated, including: documentation of the reason for stopping services and the date services are stopped. Policy complies with state law. Tips: Ensure your policy for discharge and transfer is up to date. Educate clinicians on the DC/TX policy. Audit your Discharge and Transfer summaries regularly for compliance.
9. HCPS.5 It is required that Organization policy defines: Minimum plan of care content to include scope and frequency of care and intervention; Drugs and treatments to manage client symptoms; Medical equipment and supplies needed in care delivery. Tips: Ensure that your Plan of Care for each patient is current with all medications/treatments/equipment and is revised as necessary. Educate clinicians on the requirements for the Plan of Care. Reinforce physician notification for any discrepancies. Audit plan of care/interim orders to ensure compliance.
10. HCEP.2 There is evidence that staff are trained in the emergency preparedness plan and understand their responsibilities. Tips: Ensure that Management and Staff understand the Agency Policy and are trained at least annually. Audit to ensure everyone in the Agency is following the policy. If your policy is stricter than regulations consider revisions.
A home care agency’s business is as unique as the community it serves. States CHAP SVP of Accreditation, Teresa Harbour, “Having an accreditation partner that gives you the flexibility to use your strengths, instead of giving you more hurdles, helps you succeed. At CHAP, your differentiators – professional services, personal care, companion care, or all three, define your accreditation process, saving you time and money.”
Rynkiewicz Health Care Consulting LLC is a CHAP Certified Consultant and can help you prepare for State or Accreditation surveys whether you are a new start up or an existing agency. Call us today at 215.804.9766 or contact us online to learn how we can help you with a successful survey outcome.