Common and Avoidable Survey Issues – Failure to follow the Plan of Care

We’ve established that regulators are pretty narrow-minded when it comes to interpretation of the rules.  And they have to be.  Subjectivity contaminates the process and things fall through the cracks.  In this installment of our four-part series on Survey Issues, we will explore another common challenge for home health agencies: following the Plan of Care.

We all know that, in home health, the Plan of Care (POC) is sacrosanct.  This Constitution of Patient Care summarizes the plan and goals developed by licensed clinicians acting under the physician’s orders.  There can be no deviation from this document without cause and there’s a process for that eventuality.

Visit frequencies are one area where actions sometimes fail to meet the POC.  If the plan says you will provide nursing visits twice a week, make sure that occurs.  Nursing visits three times in one week is as bad a deviation from the plan as making only one visit.  Either way, it’s considered care that wasn’t in accordance with the orders.

When a patient receives Home Health Aide (HHA) services, the nurse must prepare a plan for the aide to follow.  This plan outlines the tasks the aide will perform and the frequency.  Nurses must use great care and attention when developing these plans.  If they require a task to be performed on a daily basis, and it isn’t, you’ve failed to follow the POC. An example of this is the patient who experiences frequent constipation.  The HHA care plan states that the aide will inquire on a daily basis if the patient had a bowel movement.  Some HHA visit notes don’t even have a space for this item, so if the aide doesn’t ask the patient and document it in the comments area, you just failed to follow the POC.  If you’re tempted to dilute the frequency to PRN, keep in mind that HHAs can’t be expected to assess the need for certain activities.  The RN must specify the frequency.

Be sure to pay attention to the patient’s educational requirements and ensure all clinicians are fully informed of the topics for patient education that are mentioned in the POC.  If the POC was prepared in a fairly rational manner, the education will follow the patient’s diagnoses and medications.  However, sometimes agencies get creative with their education and mention all kinds of topics.  Just make sure that there is documented proof of the education that was committed to (and ordered) on the POC.  Caveat:  you can’t just blindly check off boxes for education.  Each note brings with it a whole host of educational requirements.  Maybe the patient had a fall.  Was there re-education on safety?  If the patient was started on a new medication, did the nurse assess for drug interactions and educate the patient on side effects and what to do in the event of a reaction?  Those items aren’t on the POC, per se, but they are warranted based on the daily interaction with the patient.

Obviously, we could list other areas of the POC where agencies seem to drop the ball, but you get the idea.  In our last discussion, we will focus on the challenges of having independent contractors.  See you then!

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