The Joint Commission recently shared its Top 5 Home Care Accreditation Program requirements identified most frequently as “not compliant” during surveys and reviews in 2021.
1. The organization implements the infection prevention and control activities it has planned: The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
2. The patient record contains information that reflects the patient’s care, treatment, or services: The patient record contains the following clinical information:
- Any medications administered, including dose.
- Any activity restrictions.
- Any changes in the patient’s condition.
- Any summaries of the patient’s care, treatment, or services furnished to the patient’s physician or allowed practitioner.
- The patient’s medical history.
- Any allergies to medications.
- Any adverse drug reactions.
- The patient’s functional status.
- Any diet information or any dietary restrictions.
- Diagnostic and therapeutic tests, procedures, and treatments, and their results.
- Any specific notes on care, treatment, or services.
- The patient’s response to care, treatment, or services.
- Any assessments relevant to care, treatment, or services.
- Physician or allowed practitioner orders.
- Any information required by organization policy, in accordance with law and regulation.
- A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient’s care, treatment, or services.
- The plan(s) of care.
- For DMEPOS suppliers serving Medicare beneficiaries: The DMEPOS prescription, any certificates of medical necessity (CMN), and pertinent documentation from the beneficiary’s prescribing physician or allowed practitioner.
3. The organization plans the patient’s care: For home health agencies that elect to use The Joint Commission deemed status option: The individualized plan of care specifies the care and services necessary to meet the needs identified in the comprehensive assessment and addresses the following:
- All pertinent diagnoses.
- Mental, psychosocial, and cognitive status.
- Types of services, supplies, and equipment required.
- The frequency and duration of visits.
- The patient’s prognosis.
- The patient’s potential for rehabilitation.
- The patient’s functional limitations.
- The patient’s permitted activities.
- The patient’s nutritional requirements.
- All medications and treatments.
- Safety measures to protect against injury.
- A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.
- Patient-specific interventions and education.
- Measurable outcomes and goals identified by the organization and patient as a result of implementing and coordinating the plan of care.
- Patient and caregiver education and training to facilitate timely discharge.
- Information related to any advance directives.
- Identification of the disciplines involved in providing care.
- Any other relevant items, including additions, revisions, and deletions that the home health agency, physician, or allowed practitioner may choose to include.
4. Identify risks associated with home oxygen therapy such as home fires. Conduct a home oxygen safety risk assessment before starting oxygen therapy in the home and when home care services are initiated that addresses at least the following:
- Whether there are smoking materials in the home.
- Whether or not the home has functioning smoke detectors.
- Whether there are other fire safety risks in the home, such as the potential for open flames.
Document the performance of the risk assessment.
5. Governance is ultimately accountable for the safety and quality of care, treatment, or services: For home health agencies and hospices that elect to use The Joint Commission deemed status option: The organization has a governing body that assumes full legal authority and responsibility for the overall operation of the organization. For home health agencies that elect to use The Joint Commission deemed status option: Overall operation of the organization includes provision of services, fiscal operations, review of the agency’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program. For hospices that elect to use The Joint Commission deemed status option: A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice.