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Top five challenging requirements identified by The Joint Commission
Following orders, reducing falls lead list of compliance issues
The Joint Commission (TJC) report on the top five most challenging requirements for home health care agencies shows that 28% of agencies surveyed for accreditation by TJC in 2009 were not compliant with the requirement to provide care in accordance with orders.
"Although we identified five specific requirements that are challenging, the broader issue is communication among everyone involved in the patient's care," explains Margherita C. Labson, RN, MS, executive director of home care accreditation for TJC. "When patients are in a hospital, they are seen by their physician, hospitalists, specialists, or a combination of physicians," she says. The challenge to home health care is to identify the clinicians who are involved in the patient's ongoing care and coordinate communication, she adds.
The most frequent reason for noncompliance with the requirement to provide care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation [PC.02.01.03], is lack of documentation for orders or physician orders that are not written clearly, says Labson. "The same home care nurse may not see the patient at every visit, so we need to remember that everyone interprets instructions differently," she says. For example, a physician order that reads, "Give two acetaminophen every four hours for fever" may seem clear, but Labson points out that fever is not defined. "I may think that 99 degrees is fever, but another nurse might not think a patient has a fever until the temperature is above 100 degrees," she explains. The physician order should include a definition of fever for the specific patient, she adds.
Another issue for home care, especially hospice, is the failure to write telephone orders on the chart, says Labson. "A nurse will contact a physician for permission to give acetaminophen for fever, but she won't write it in the chart," she says.
"We also never want to see an order that indicates the patient can 'resume all medications' after discharge to home health," says Labson. This phrase was very common in the past; but it is dangerous for home care patients, because they may be discharged with new medications that may interact negatively with medications they were taking prior to their hospital stay, she explains. The order for resumption of medications should identify each medication by name, along with the dosage, she says.
Falls reduction program
The second most challenging requirement for home health organizations was the National Patient Safety Goal that addresses the reduction of patient falls [NPSG.09.02.01]. Twenty-one percent of agencies failed to comply with the patient safety goal. "Falls are the leading reason for readmission to the hospital, so this is a critical requirement for home care agencies," says Labson. One reason some agencies fail to meet this requirement is that they focus their fall prevention efforts on elderly patients, she says. "There is a misconception that falls only occur in the elderly population, but a medically fragile child can easily fall; or the child's caregiver might be at risk of falling if the environment is not safe," she says. Of course, Labson also reminds home health agency staff to document every assessment, recommendation, and discussion with the family.
Documentation is also important when it comes to verifying a potential employee's qualifications, as well as staff member's competence to perform responsibilities [HR.01.02.05 and HR.01.06.01], says Labson. These requirements were the third and fourth most challenging requirements for home health care agencies, with 20% of agencies found not to be in compliance in these areas.
"We verify licenses with the nursing or other license organization before we hire any employee," says Juliet Falar, RN, director of nursing for 24/Seven Health Care Services in Chicago. "We also contact previous agencies listed on the applicant's resume to confirm experience and responsibilities," she says.
"Licenses must be verified with a primary source, such as the state organization issuing the license," Labson explains. "Often, this is not an issue for new hires, but it is an issue for employees whose licenses have to be renewed at different intervals," she says.
An agency should set up a process to recheck licenses on a regular basis, suggests Labson. "When I became a nurse, my license had to be renewed in the same month that I originally received it, but many states have moved to renewals that occur once a quarter, or at specific times of the year," she says. Set up your process to reflect the requirements of the licensing boards with which you interact, she says. Also, your process must be proactive; you cannot rely upon employees to notify you of renewed licenses, she adds.
Only 16% of home care agencies failed to comply with the requirement to identify risks for acquiring and spreading infection [IC.01.03.01], but this is a requirement that should be easy for organizations to meet, says Labson. "Look at what infections are occurring in your community; then identify the risk of infection among your employees and patients," she says. The assessment of risk must be community-specific, because different infections appear in different populations, she explains. "In my area, tuberculosis is not an issue, but hepatitis B is a huge issue," she says. "Home care agencies should address the infections that are the greatest risk in their areas in order to best protect their patients and employees," she adds.
For more information, contact:
Juliet Falar, RN, Director of Nursing, 24/Seven Health Care Services, 3318 W. Peterson Avenue, Chicago, IL 60659. Telephone: (773) 463-3755. E-mail: firstname.lastname@example.org.
The Joint Commission Standards Interpretation Group, The Joint Commission, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5900. Fax: (630) 792-5942. To complete the online question form for standards questions, go to www.jointcommission.org and select "online question form" under the "standards."