Getting Ready For Hospice Survey In 2021 or 2022? Keep Your Eye On The Top 10 Accreditation Citations And Avoid Them!
August 16, 2021
Top 10 CHAP Hospice Survey Deficiencies In 2020:
The Community Health Accreditation Partner (CHAP)
has compiled the top 10 list of deficiencies cited during hospice surveys in 2020
. These are the items listed in their reference materials as of May 20, 2021.
- L626: This L tag refers to the aide providing services in accordance with the plan of care and as ordered and permitted by training. Tips: Communication is key here. Make sure assigned tasks are completed frequency of visits is followed. Discuss this is IDG meetings and have a system in place to communicate changes to the aide.
- L545: The standard states the is an individualized care plan with goals/ interventions based upon problems identified in the comprehensive assessment. Tips: Here is where agencies should utilize the IDG to review identified problems and correlating intervention as well as goals. Auditing should be in place to make sure changes are updated within the care plan. Ultimately, what is documented in the comprehensive assessment should look like the same patient in goals and interventions.
- L543: This regulation states that h ospice care and services follow an individualized written plan of care. Tips: This is all auditing to make sure your clinicians are following the plan of care.
- L678: This L tag states is about the clinical record being complete with all the required elements including the physician orders. Tips: This is another compliance issue that can be addressed and maintained through routine clinical auditing.
- L530: L530 is the comprehensive assessment including a drug review. Tips: Make sure clinicians are capturing over-the-counter meds as well as herbals in the med list. This is something that needs addressed each visit to validate the current meds are still current with no additions or subtractions. Review the clinical documentation to make sure the med profile has all medications listed.
- L553: This L Tag refers to the revised plan of care including current information from latest assessment and progress towards outcomes. Tips: All new and ongoing problems have to be addressed with interventions and goals. If there is no progress towards those goals, then you may need to look at different interventions to more effectively address the goals. This is where revision of your care plan is vital to make sure it addresses the patient "seen" in the assessment.
- L625: Written aide instructions are developed by the RN. Tips: This is an ongoing record review item. Reviewer needs to make sure the aide instructions are specific to the needs of the patient. Again, the aide instructions should mirror the patient your documentation shows in the assessment. If there is a mismatch or no specificity, there will be a problem. Reviewer also needs to make sure the RN is the one that prepared the aide instructions.
- L523: This tag is related to timing of the initial and comprehensive assessment. It can be completed no later than 5 days after the benefit election. Tips: You need a system in place to ensure all core disciplines are aware of when a patient was admitted. Use clinical auditing to ensure compliance and make sure that IDG members were involved in the completion of the assessment.
- HIPC.9.1 L Tag: N/A: This is not an L tag but a CHAP standard and part of the top ten. This is your TB screening per regulations and CDC guidelines. Tips: Your surveyor will review your agency's TB program to ensure it is current with regulation/ CDC guidelines. If testing is required, then you need to have successful tracking to ensure you are following timeframes.
- L579: This L Tag references following standards of practice to prevent infections including standard precautions/ hand hygiene. Tips: This should be closely monitored during supervision visits in the field. This is also part of the top 10 on the home health citations. Do not take for granted staff knows and is practicing hand washing per your policy or following routine infection control.
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