Home Health: Top 10 Deficiencies for 2023

Join us for an insightful episode as we dissect the top 10 home health deficiencies for 2023 with CHAP's esteemed Clinical Nurse Educator, Keri Culhane. With decades of expertise in post-acute healthcare, Keri sheds light on persistent issues and emerging trends in care planning, emphasizing the critical elements of the plan of care and the necessity for individualized care plans. Understand why "cookie cutter" approaches often driven by electronic medical records (EMRs) are falling short and discover new deficiencies around maintaining complete records and conducting timely initial assessments. Keri also offers practical strategies like using SMART goals and customizing EMR processes to enhance compliance and improve care quality. Our conversation also covers critical infection control practices, with an emphasis on hand hygiene and bag technique during field visits among other essential information. Listen to find out. 

Click below for:

1. Upcoming Accreditation Intensives 
2. PDF of the Top 10 Home Health Deficiencies for 2023
3. CHAPcast: Hospice Top 10 

Be sure to listen for details on our upcoming micro-learning sessions dedicated to individualized care plan development, designed to help you meet and exceed CHAP standards. 

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Transcript

Top 10 Home Health Deficiencies Analysis

Speaker 1 0:00

Greetings. I'm Jennifer Kennedy, the lead for Compliance, quality and Standards at CHAP, and welcome to our CHAPcast. In this episode we're going to talk about the top 10 CHAP home health standard deficiencies, their underlying trends and some strategies for success. So, whether you're a seasoned provider that's been around the block for a while or new to the field, we're hoping today's insights will arm you with the knowledge to not only meet CHAP standards but exceed them. So I'm going to be talking with Carrie Culhane today. She is our CHAP education primary person with our CFE department, or arm of our business.

Speaker 1 1:17

And Carrie does come back to CHAP and I say back to CHAP. She was with CHAP as a director of accreditation in the past. Back to CHAP. She was with CHAP as a director of accreditation in the past. She has a wealth of experience in the post-acute healthcare industry and she has held a variety of positions, from providing direct patient care as a registered nurse to being a chief executive in both home health and hospice organizations. Like myself, sherry, sherry Carrie has a passion for community-based care and she does enjoy educating others and helping them grow and develop as healthcare professionals. So, as CHAP's clinical nurse educator, she has the goods. If you will. She has the goods, if you will, with an MBA and a nursing degree, to be a powerhouse of practice, a true expert in standards, quality and education. So welcome to CHAPCAST.

Speaker 2 2:16

Keri. Thank you, jennifer, I'm glad to be here.

Speaker 1 2:19

Well, you are going to be the expert in this conversation when we unpack the top 10 deficiencies in home health care, but why they may be happening and how an organization can correct them to help them move their quality forward a couple of notches and you know, essentially get into a better alignment of compliance. Sure, so let's kick things off by talking about any new things you're seeing on the top 10 list, and then we're going to be talking about the 2023 list, but are you seeing any trends or new things on this year's deficiency list?

Speaker 2 3:18

So this year we have a few different trends going related to the top 2023 deficiencies for home health. First, we have our top two deficiencies related to care planning or the plan of care content elements itself, as well as written instructions to the patient. Those two top deficiencies remain the same compared to 2022. We've also noted there are several deficiencies that remain in the top 10 overall. They may have just moved in terms of their ranking within that top 10. And then we did have a couple of new deficiencies come into the top 10 this year that are new and they came in at numbers 9 and 10, respectively, and those have to do with maintaining current and complete records, so including all of your assessments, your clinical notes, orders, care plans, etc. And then the last one is timely completion of that initial assessment, really focusing in on that 48-hour mark of referral patients return home or on the allowed practitioner started care date.

Speaker 1 4:27

So that's really interesting. I'm not too surprised about the care planning, because it just seems like, whether it's home health or hospice, providers have a lot of difficulty with care planning and having that stay out of top deficiencies. So you gave us sort of a quick look into a few of these deficiencies. Do you think you could run the list for us?

Speaker 2 4:53

Yeah, absolutely so. As you mentioned, care planning coming in at number one has really been a problem area for organizations for several years and we've seen that in our data that we run. And so really what that's focusing in on is making sure that all the contents of the individualized plan of care are present and complete, and what we're looking at is making sure that those goals are developed. We like to use the term smart goals, so really they're specific, measurable, achievable, realistic and timely.

Speaker 2 5:30

Also, focusing in on individualization of the plan of care, we see a lot of what I like to call cookie cutter goals and interventions where they're not specific and individualized to what the assessment is demonstrating through that process and really focusing on what those patient needs are, specific to their individualized components of the assessment.

Speaker 2 5:53

And then also making sure organizations are potentially looking at a performance improvement project or making sure that they're pulling in care planning in terms of indicators in their quality program through an audit process or however that looks for that organization and making sure that they're taking a deeper dive into those plans of care. And one thing of note is because plans of care seems to be the top deficiency several years running and we see organizations struggle with really developing that individualized component. We will be putting out what we like to call a micro learning here very soon where it's focusing in on specific care plan development for both home health and hospice and really breaking it down at the granular level on really how to build an individualized care plan. So stay tuned for more to come on that.

Speaker 1 6:47

So, carrie, let me ask you a question just before we come off of plan of care Do you think the current electronic medical record situation contributes to some of these deficiencies that we see?

Speaker 2 7:04

I would say yes, you know, in my experience of surveying for several years and experience with different EMRs across the country, there are a lot of EMR systems that focus more in on, like I mentioned earlier, that cookie cutter type intervention goal development.

Speaker 2 7:22

And one of the things that is really important that organizations need to be able to do is customize that process. So whether that's working with their EMR directly or just learning the process, and maybe the EMR already has that ability to be customized and they just need to understand the importance of being able to individualize those goals and interventions to meet the patient's specific needs. And so you know, when you're looking at care plans they don't all look the same and have those same goals and interventions, but you can really see that individualization. And so I think it's been a struggle for organizations because EMRs in a sense have kind of taken some of that critical thinking ability away from clinicians as they're developing those plans. So really encouraging organizations to put that critical thinking factor back into that process and customize those goals and interventions, that you can really see that individualization for those patients, yeah, I couldn't agree more.

Speaker 1 8:23

You know it's point and click just doesn't make it. It just doesn't make it. You have to take that time to show Mr Smith in your documentation how he is, how he's functioning, et cetera. So yeah, that's great, and that's great about the micro learning sessions as well. I'm sure they're going to be really helpful.

Speaker 2 8:46

I truly hope so and, like I said, because it's such a challenge we see in the industry, we felt that was a great need to be able to fulfill and providing organizations with some guidance related to care planning.

Speaker 1 8:58

Well, that's great. What else is on the list related?

Speaker 2 9:02

to care planning. Well, that's great. What else is on the list? So coming in in?

Speaker 2 9:08

Second is really providing those written instructions to the patients, and that really focuses in on specifically what we noted is related to that visit schedule and really making sure that when all disciplines if there's multi-disciplines ordered on the case, that each discipline, after they go and do their assessment and are developing that plan, are really providing patients and their families, caregivers, with a visit schedule of how often and when they're going to be coming out and making those visits and so that really I think we see that more on the back end.

Speaker 2 9:38

So started care we typically see that nursing do a great job of their opening the case and providing that frequency and that visit schedule. But where we see that struggle is when we have other disciplines that come in after Maybe you have a therapy evaluation coming in after the fact and sometimes they're not putting that information down or jotting that down and providing it to the patient. So really making sure all of those disciplines are providing that visit schedule to the patients and there's not necessarily a specific way that has to be communicated. The intent of the standard is just to provide that information, whether that's in a calendar form, or you're writing it down on a piece of paper, or however you can meet the intent of that standard. That's what we're going to be looking for, just that. That when we go out on those home visits and ask those questions, you know we can either see that in documentation the patients and families are able to speak to that process, so we can see that information is being provided.

Speaker 1 10:37

It should make sense to the patient too. They prefer a calendar.

Speaker 2 10:41

do a calendar If they want it written in their little spiral bound notebook.

Speaker 1 10:46

Put it in there.

Speaker 2 10:48

Yes, and sometimes we see it on the start of care documentation.

Speaker 2 10:50

They leave blanks there.

Speaker 2 10:51

So it really can be accomplished in several ways and we just want to see that it's documented somewhere and the family and patient can speak to when their staff members are going to be coming out and making those visits.

Speaker 2 11:05

And then, following that, we have evidence of timely transfers and discharge summaries and making sure the content of those summaries are comprehensive. And really what we're looking at is either for discharge, we're looking at that five-day window to make sure that that's provided to the practitioner, or, if it's a transfer, we're looking at that two-day window to make sure that that transfer summary is provided to that facility. And so that comes in at number three. And really where we're seeing that issue is really related to the timeliness. So making sure that there is a process in place for organizations to be able to track and make sure they're meeting that the five-day window for the discharge and the two-day window for the transfer, and then be able to show during a survey, show the site visitor, what that process looks like and how they're able to track and meet the intent of the standard and the timeliness of those two components. And then fourth and for me this is a big one I'm surprised it actually isn't One of the top two actually is related to comprehensive medication review and developing that comprehensive profile.

Speaker 1 12:16

Oh, here we go. Medication reconciliation right.

Speaker 2 12:21

Here we go Medication reconciliation right, absolutely. So this is a big one. And when we do our accreditation intensives, what types of questions they can be asking the family, the patient, learning how to be what I like to call a detective, and keeping your head on a swivel when you're in that home and looking around and seeing what other medications might be visible, asking those questions, and so that's really part of that process. And then also making sure that that information is getting communicated and documented accurately and completely in the record, because a lot of the issues we might identify is there may be discrepancies or inaccuracies is what the patient has in the home compared to what might be in the clinical record also. So not only doing that reconciliation in the home with the patient, then making sure they have that accurate record left in the home, but then taking that other step and making sure it matches what's in the clinical record as well.

Speaker 1 13:32

Yeah, I think that's probably a big gap is, you know, the clinician doing it, actually doing the med rack and making sure the list in the home is updated, but then getting it back to the clinical record? I think is always you know, a fall down area, you know. So that's hard, that's a difficult one to master.

Speaker 2 13:56

And I think the other thing we see too is not necessarily questions being asked and meds being reconciled every visit and really what we focus in on and what I like to share with organization is that's best practice if you're having your clinicians really do that whole reconciliation process every visit, every time to really identify any discrepancies and make sure that that list is as accurate as possible.

Speaker 1 14:21

Couldn't agree more.

Speaker 2 14:24

And then coming in at number five, is timely and appropriate use of the Noticare of Medicare non-coverage form. And typically what we're seeing mostly with this it has to do with the timeliness of meeting that two calendar day window, 48-hour window, of making sure that the patient family have that form, are aware of their ability to appeal the decision of discharge prior to that discharge taking place. So most of the deficiencies related to this standard have to do with that timeliness of delivery and making sure that they're provided that information in advance. The other part to that is making sure that that notice of Medicare non-coverage form is accurate and complete. We also see inaccurate QIO or quality improvement organization information that is listed on the form. That because that's who they would call if they do want to file an appeal and dispute their discharge. So that is also an issue that we're seeing is that that form is not completed accurately with their correct information.

Speaker 1 15:34

Yeah, I think I just, Carrie, saw a change in Kepro. You know, because these contracts revolve all the time, you know they're only like two-year, maybe three-year contracts with CMS. So, yeah, absolutely need to keep an eye on that and I'll put the update of that Kepro in our next compliance monitor.

Speaker 2 16:02

Oh, perfect, okay, and that's another thing is making sure the organizations have a good understanding of who their QIO is in their region, because sometimes I've seen another QIO, like you say, kepro or LaVonta, and maybe they're in a different region and they don't have that accurate info.

Speaker 2 16:20

So it's really important they understand who their current QIO is for their region.

Speaker 2 16:27

And then, coming in at number six has to do with skilled professionals following that plan of care, and the most common deficiency related to this is the visit frequency issue and documenting those missed visits.

Speaker 2 16:41

And that really, out of all of the physician order components and following physician orders, that really comes in as number one under this deficiency. So making sure that indeed, if there are missed visits, that those are documented appropriately, the provider is notified and that's documented in the record and they have a, they have a organization has a process in place to audit that, because that is, it's for sure, an area that the site visitor will be focusing in on, and making sure that each discipline is meeting those visit frequencies as assigned and documented in the plan of care and if not, whether it's, you know, the patient refusal or perhaps they can't get a hold of the patient, whatever the issue may be that that's documented appropriately and captured in the record to support why that missed visit did occur. And then I'm going to speak to seven and eight together, because they both have to do with infection control and we're focusing in on hand hygiene as well as bag.

Speaker 1 17:40

I'm going to have to fall out of my chair now. I'm sorry, goodness, gracious. Out of my chair now. I'm sorry, goodness gracious.

Speaker 2 17:47

Yes, these ones continue to pop up, although they do migrate.

Speaker 1 17:54

in terms of their ranking, they do continue to be in the top 10. You know, I thought after COVID everyone would just have the most squeakiest clean hands and flawless processes for infection control.

Speaker 2 18:05

You would have thought so. You know, and it's so interesting because you know surveying during the COVID period, I actually saw an increase in inappropriate glove use as it relates to the process and I think you know we were seeing a lot more clinicians wearing gloves but they weren't really understanding the appropriate way to be using those gloves and when hand hygiene needed to be conducted and gloves changed etc. So it was actually very interesting from a surveyor perspective to see that during the COVID time. But we still continue to see this, even post-PHE, be an issue and really it's hard because it's such a basic functioning. You think hand hygiene is just something that we learn, you know, even as little kids and growing up, and just basics of hand washing, but it is something that pops up and we do again in our intensives. We really tackle infection control issues and break it down and really what's so important is observing the staff in the field when it comes to infection control practices. You know I can't stress enough how important it is to be conducting those field visits, supervisory visits, where you're able to observe the staff in that uncontrolled environment, see how they're able to set up their workspace. You know, have a clean section. You know it's it's. It's one of those things, because we can't control the patient's environment and you never know what you're going to walk into and and so it's really important that they're able to be observed and and provided guidance and instruction in that process, in that real world environment, and and, of course, as much ongoing education and training. You know they say repetition is the key to adult learning. So continuing to provide staff with education on the correct processes of hand hygiene, bag technique. The more they repeat it it becomes part of their routine. And then when they're out with a, with a site visitor, surveyor, because it's so routine for them hopefully you know that the nerves may kick in a little bit because they've gotten such a routine down that process will hopefully, you know, flow through that visit. At least that's the hope. So the more they're getting that education and observed by their clinical leadership, the more they're going to be prepared when a site visitor walks in their door and is observing them out in the field also. When a site visitor walks in their door and is observing them out in the field also and then coming in at number.

Speaker 2 20:33

These are the two new ones, so nine and 10. So nine is the current record, making sure it has all of those clinical notes, assessments, plans of care, orders, et cetera. So making sure that that clinical record is accurate, complete. And that really will entail making sure that clinicians are completing their documentation as well as completing it timely. I know a lot of EMRs now. You know you have the ability to you know, to save notes and come back to it later and oftentimes you might go out and see where there might be a draft of a note in that EMR but the clinician didn't actually go back and complete the note. Maybe their narrative is missing, whatever the case may be. So having processes in place to be able to audit that record and make sure that those visits and those documentation components are complete, and also completed and filed timely according to organizational policy, you know, organizations do have differing requirements in terms of how, when that documentation needs to be completed and submitted by.

Speaker 2 21:32

And then number 10, the last new one here, is the timely initiation of that assessment. So with making sure that the initial assessment is completed within that 48-hour window and that's either of the referral or when the patient returns home perhaps they were hospitalized and they're coming back a resumption or on that allowed practitioner's ordered start of care date. So making sure that the documentation reflects that If there is a specific reason as to why it is not occurring within that 48-hour window, that the documentation reflects what that reasoning is. You know, perhaps the patient is requesting you know it to be on a certain day and they don't want that clinician to come within that 48-hour window. The documentation and the record really needs to reflect that and support why that standard was not met. And also, of note, just one thing to mention on this, because when Appendix B was revised and in those interpretive guidelines, one of the things that they really call out is that it is not okay for an organization to not meet that 48-hour window due to staffing issues.

Speaker 2 22:38

So that cannot be a reason why they're not meeting that 48-hour window. Cms is very clear about that. And one last thing, jennifer, I just wanted to mention, as I just mentioned, the revised Appendix B, and I know we're not going to get into a lot of that, but what I do want to say is all of these standards that are falling into the top 10 all crosswalk to level one standards that CMS has identified. So all of these issues would be issues that are addressed on a CHAP survey, of course, but then also, if a state surveyor were to walk in and conduct a standard survey, all of these issues would be a level one standards that would be addressed. So very important that all of these organizations are compliant with them, because it is such a focus related to compliance.

Speaker 1 23:31

Wow, man, you're just a wealth of information and you've given a lot of good rationale, let's say rationale behind the deficiencies, the whys and even some strategies for improvement. So we do do a deeper dive into our standards and those are via our CHAP accreditation intensives, and I know that you are the main instructor of those. Any thoughts you want to give our listeners about the intensive for home health?

Speaker 2 24:13

So home health. We do several of them throughout the year and we really take every single chapter in our home health standards manual and break it down. We break down each standard. We go over what those requirements are in order to meet the intent of those standards. We talk about the deficiencies we're seeing in those chapters specifically, so even drilling down further into that deficiency data and then helping organizations with tips for success we like to call them so at the end of every chapter that we go over, we're really talk about ways that they can demonstrate compliance with these top deficiencies we're seeing in these chapters. We also do a lot of scenarios, we do discussions. We make it a very interactive session so that participants can get the most out of it in terms of learning not only from us as instructors, but also learning from their peers attending the course. Also when we put them into breakout rooms and have them work on scenarios and activities together and so they really can network and develop other relationships as well as learning from what others are doing out there in the industry.

Speaker 1 25:22

That's great, I think, for our listeners. That is a do not miss for our CHAP intensives about home health. So, Carrie, thanks so much for joining us today to run down that list of top home health. So, Carrie, thanks so much for joining us today to run down that list of top home health deficiencies. You can find details on our website and in the episode notes, as well as the PDF of our top 10 deficiencies that we talked about here today. We'll give you the links to our website for those. And please, if you have a moment, take a look at our website, our education page, and look at all the information that is available about our upcoming accreditation intensives.

Speaker 1 26:10

And, to those of you listening out there, stay tuned for our next episode where we're going to talk about the top 10 hospice deficiencies which you know joining into. That is going to be essential for you to not only be compliant but elevate your care. All right, Well, we've come to the end and I want to thank all of you out there for taking time out of your day to listen to our podcast From me and the entire CHAP staff. Keep your quality needle surging forward. Stay safe and well, and thanks for all you do. Thank you.