Avoiding Deficiencies through Defensive Documentation & Following Standards

1. Avoiding Deficiencies through Defensive Documentation & Following Standards Suzi Hamlet, RN, MSN

2. Documentation • If it’s not documented, it was not done. • The clinical record should read like a novel, not a mystery. • Documentation must paint the picture of the patient.

3. Documentation • Main point - The clinical record is the only thing you have to prove the clinical staff provided care (usually a visit note, comprehensive assessment or therapy evaluation). • The documentation in the clinical record is your proof of what care the patient received and why the patient needed that care. • The documentation in the clinical record must paint the picture of the patient.

4. Common Deficiencies Cited In Home Health: • Plan of Care • Comprehensive Assessment • Nursing Services • Coordination of Care • Compliance with Federal/State/Local Laws and Professional Standards • Therapy

5. Common Deficiencies Cited In Hospice: • Plan of Care • Comprehensive Assessment • Drug Regimen Review • Nursing Services • Supervision of Aides • Aide Assignment/Plan of Care

6. Survey Process • What are surveyors looking for during survey? • That the clinical staff provided care as ordered on the plan of care and interim orders. • Care was individualized to the patient's healthcare needs. • Any changes in the patient’s condition were communicated to proper staff and physician. • Coordination of care between all appropriate staff and providers. • The staff are following agency policy and procedures. • Looking for the who, what, when, where and why.

7. Survey Process • How do surveyors determine the agency is in compliance with regulations? • Clinical record review • Home visit observation • Policy and procedure review • Staff education • Staff competency • Chart audits • PAC, Governing Body, etc.

8. Survey Process • Clinical Record Review • Plan of Care • Medication List/Medication Profile • Comprehensive Assessment • Updated/Interim Orders • Visit Notes for all disciplines seeing patient • If Aide, review aide assignment, aide visit notes and supervisory visits • If therapy, review therapy evaluations

9. Plan of Care • Patient’s diagnosis/diagnoses • Physician orders • Medication list • Discipline(s) frequency of visits • Patient Goals (Individualized)

10. G158 Care Follows a Written POC • Failures include: • Frequency of visits not followed • Visits are ordered for specific day, and are not done on that day • Lab work ordered, but not completed or results not reported • Wound care not provided as ordered • Orders on POC to assess pain and pain management, not addressed in visit notes and patient assessment • Orders on POC to assess respiratory, cardiac, or neurological status each visit, documentation during comp assessment and routine visits fails to address assessment

11. G159 POC Complete & Consistent with Patient Assessment • Failures include: • POC is Inaccurate, Incomplete or Missing • Sometimes see duplicate orders for certain disciplines • Inaccurate dietary orders, patient has regular diet ordered, but is diabetic with insulin/BS testing ordered • Inaccurate/incomplete med orders, fail to include dose, route, or frequency • POC failed to include RN verbal order signature and/or physician signature • POC includes orders for SN to assess HTN, DM, etc. but those diagnoses are not included on POC

12. Comprehensive Assessment • Each patient must receive, and an HHA must provide, a patient specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient’s medical, nursing, rehabilitative, social, and discharge planning needs.

13. Comprehensive Assessment • Patient’s physical assessment • Screenings for dietary, wounds, fictional ability, fall risk(s), etc. • Mental status and educational need/ability • Living status, needs assessment • OASIS Date Items

14. Comprehensive AssessmentDrug Regimen Review • The comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including: • Significant drug interactions (all meds) • Ineffective drug therapy • Significant side effects • Duplicate drug therapy • Non-compliance with drug therapy

15. Comprehensive Assessment • Drug Regimen Review for Therapy Only Cases • Drug review must be completed by the RN within five (5) days of the start of care and other time frames for comprehensive assessments. • RN must provide high-risk drug education to the patient/caregiver .

16. Comprehensive Assessment • High–Risk Drug Education • Each agency is allowed to develop their own list of high-risk drugs related to their patient population • Develop policies and procedures related to high-risk drug education • Identify high-risk drugs taken/ordered for the patient • Document patient/caregiver education related to high-risk drugs

17. Coordination of Care • G143 Coordination of care occurs between all disciplines/care providers • Staff fail to ensure coordination of care • Initial Comprehensive Assessment identifies needs but staff fail to follow-up with identified needs • G144 Coordination of care is documented • Staff fail to document coordination of care • Case Conference Notes fail to include changes identified in visit notes

18. Teaching/Education • Teaching/Education of patient or caregiver related to: • Diagnosis • Treatments (wound care, Foley care, PICC, etc.) • Medications (Skilled Nurse to provide) • Pain relief • Safety • Home exercise program

19. Nursing Documentation • Diabetic Assessment/Management • Start of Care Comprehensive Assessment needs to show the patient’s/caregiver’s knowledge of the disease process and ability to care for them self • Glucometer • Insulin administration • Dietary restrictions • Blood sugar log • When to report hypo-/hyper- glycaemia

20. Nursing Documentation • Diabetic Assessment/Management • With each routine visit: • Review of blood sugar log • Review of patient education/ability to perform needed tasks • Teaching (if needed) • Review compliance with diet restrictions • Address orders on POC, foot care, etc. • Reassess patient needs

21. Nursing Documentation • Pain Assessment, Comprehensive Assessment • Location, quality, intensity, type of pain • Does patient have pain medication ordered • Twenty-four (24) hour history of pain, including medications taken (Rx and OTC) • What is the patient’s pain goal • Patient’s satisfaction with pain medication/therapy provided

22. Nursing Documentation • Pain Assessment, Ongoing Assessments: • Assessment of pain at each visit • Document what patient is doing/taking for pain relief (exercises, meds, OTC, herbal) • Consistently assess and document if patient is satisfied with level of pain control • Document patient and caregiver response to education provided • Document patient's compliance with pain management provided. What does the patient say?

23. Pain Therapy • If using Ice, Heat, Tens, or other modalities, MUST obtain order for these modalities. • Order MUST include, location, frequency of use, length of use and settings, if applicable.

24. Nursing Documentation • Wound Assessment including: • Location • Measurement (length, width, depth) • Appearance of wound bed and surrounding tissue • Describe tissue in wound bed • Drainage • Odor • Pain

25. Nursing Documentation • Wound Care Documentation: • Specific wound care provided, if multiple wounds document for each wound. • If staff document “wound care per physician’s order”, MUST document the date of the wound care order being followed. NOTE: Before the patient/caregiver independently provides own wound care, the SN should document teaching and return demo by patient/caregiver of wound care/dressing change.

26. Therapy Documentation • Are therapist providing care as ordered on POC? • Frequency of visits • Provided care as ordered • Updating RN as needed for changes in condition • Notify physician of changes • Supervision of COTAs and PTAs • Timely evaluations

27. Therapy Documentation • Pain Assessments – same as nursing documentation • Therapy provides Start of Care Comprehensive Assessment, remember this assessment must address patient assessment and diagnosis • If patient is Diabetic, need to assess at SOC. • All medications must be documented, and patient education needs assessed and provided by RN.

28. Professional Standards • Professional Standards • Infection control • Nursing and Therapy Staff placing bags on floor • Staff not cleaning equipment after use • Entering bag with gloved hands (after providing care) • Wound Care/Treatment • Clean to dirty technique • No barriers for supplies • Nursing Assessment • DVT assessment and documentation • Medication review, education and assessments

29. Aide Documentation • RN develops appropriate written aide assignment/aide plan of care • Aide follows the aide assignment • Aide notifies SN of changes in patient’s condition • RN supervisory visits completed every fourteen (14) days • Aide competency exams include all skills aide is providing to the patient

30. Electronic Medical Record • Charting by exception (Point and Click Documentation) • Printing the record • Case Communication Notes, need to be dated and signed by staff that developed the note • All documents in the clinical record need to have agency information and need to include identifying information r/t the staff member that created the document • Watch for typo’s

31. Strategies to Avoid Future Deficiencies • Ensure policies are up-to-date and follow national standards • Ensure staff know and follow your own agency policies • Educate staff r/t agency policies, including required documentation • Ensure staff are competent and follow professional standards/best practice guidelines • Supervise field staff to observe actual practices, observe for competency • Competency evaluation of all disciplines

32. Strategies to Avoid Future Deficiencies • Ensure Staff: • Document complete diagnosis specific assessment • Document a complete pain assessment / management • Document complete set of vital signs (if applicable) • Document treatments performed during visit • Document complete wound assessment • Document physician communication • Document coordination between disciplines • Document complete patient education r/t medications, treatments or disease specific processes

33. Strategies to Avoid Future Deficiencies • Quality Improvement/Performance Improvement (QAPI) • Quarterly chart audits • MUST BE REVIEWED FOR CONTENT • Are staff following POC/interim orders? • Are changes in patient’s condition reported and followed up on? • Does the comprehensive assessment and routine visit notes reflect patient’s current condition?

34. Strategies to Avoid Future Deficiencies • QAPI NOTE: • If agency is proactive and finds their own deficient practice(s) or documentation, and has implemented a corrective action plan that eliminates future reoccurrence of the deficient practice, before surveyors arrive, most of the time the deficiency won’t be cited if we find it is already corrected.

35. Strategies to Avoid Future Deficiencies • Review clinical records and staff documentation • Educate staff • Competency test staff • Keep policies up to date • Involve PAC and Governing Body • Follow-up with concerns