Joint Commission: Are you in compliance with 5 problem areas?
Joint Commission: Are you in compliance with 5 problem areas?
Pay close attention to these frequently occurring problems
You may not be able to see the future, but talking to those who have been there before is the next best thing when trying to anticipate problems you'll encounter in a Joint Commission survey.
Proper preparation for a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations can be critical to your success. It's still no open-book test, but knowing which areas give other agencies problems can help you avoid making the same costly mistakes and enable you to focus your compliance efforts on certain difficult aspects of the standards prior to your survey. In this issue, home care surveyors and professionals share with Hospital Home Health the five main pitfalls and their tips for complying with each:
Pitfall 1. "But our agency doesn't provide that service . . ."
Yes, but your hospital does. Many agencies fail to realize that all home care services are eligible for survey, even those home services that are provided through the hospital and not the agency, says Kathy Morgan, MPH, BSN, RNC, a partner and consultant with Homecare Education Specialists, a national home care consulting company in Johnson City, TN. Joint Commission surveyors often look at other departments in addition to home health.
Services provided at home such as nutrition, pharmacy, physical therapy, respiratory therapy, and home medical equipment provision can also be surveyed. You think you're safe because these other services were not directly provided through the home health agency, and they were already reviewed by a hospital surveyor? Think again.
"When a hospital employee from a department other than home care, such as a staff member from the maternal child program, dietitian, or enterostomal therapy nurse, visit a patient's home, many times the hospitals are not aware those services are considered home care services and must meet the intent of the Joint Commission's home care standards," says Mary Friedman , MS, RN, CRNI, a Joint Commission home care nurse surveyor based in Marietta, GA.
A frequently overlooked area, according to Friedman's experience, is the well baby, new mom follow-up program. When an individual from the nursery or postpartum unit makes a follow-up visit to the patient's home, such services most definitely come under the Joint Commision's jurisdiction.
Morgan points out that some hospitals erroneously believe that low volume and payer sources are reasons for departments other than the home care agency to escape Joint Commission surveyors.
"A lot of hospitals send patients home who don't have insurance coverage and provide services such as home pharmacy drugs and think that because the patients are free care that doesn't make them eligible for survey. But it potentially does because it is not dependent on payer source," says Morgan.
Include hospital in home care's preparation
Both Morgan and Friedman caution that home care that is not performed through the main home care department can potentially be eligible for survey under home care standards. "Those services must meet the intent of the home care standards and would be included in the scope of the home care survey," she says.
Friedman says the easiest way to overcome this problem is for home care program directors and their immediate supervisors at the hospital to look at the other departments that may be providing home care services and notify them of the potential for audit by the Joint Commission. They also should supply them with Joint Commission standards for their respective services. This ensures no department will be caught entirely off guard.
Consider doing more than informing other departments that they must comply with the home care manual and providing the date of the survey. Include other departments that provide home health services in any preparation for your Joint Commission survey, such as mock surveys or work with consultants.
Pitfall 2. Failure to adapt hospital policies adequately to the specific yet different needs of your home health department.
Many hospital policies and procedures do not translate well into home care. One area that typically doesn't address home care issues is infection control. Many hospital policies require placing a patient in isolation or a special room, such as a negative pressure room for a tuberculosis (TB) patient, when such measures simply aren't feasible in the home care setting.
But there's no need to start from scratch, according to Morgan.
"It sometimes works well for the home care component to go ahead and use hospital policies as the basis for those procedures," Morgan says. "But they literally have to go through those policies page by page, word by word, and make sure that whatever the policy says is what they're going to be doing in the home care program or revising the policy so it fits nicely into home care."
Morgan says key areas falling into this category are TB control policies, hand washing policies, and surveillance systems for tracking infections.
For example, hospital hand-washing policies are often elaborate, sometimes calling for a five minute hand scrubbing, similarly not practical for home care.
Friedman says hospital policies for other areas often need modification to meet home health standards, such as:
* Emergency preparedness plan.
Hospital emergency preparedness plans often require evacuation of the hospital building. For home care, an emergency preparedness plan would call for getting staff to patients' homes rather than initiating evacuation measures. A plan calling for moving patients from one hospital wing or building to another would be of no value to a home care agency. Modify or rewrite the policy to allow for staff to make sure home care patients will continue to get the care they need in an emergency.
* Incident reporting policy.
This must take into account incidents or accidents that could occur in the home care program, such as motor vehicle accidents for staff. Again, Murphy notes that you must specify the policy to home care. A hospital policy would not account for nurses traveling to see patients, so the policy would have to be modified to account for such a work environment.
Another example of modifying an incident reporting policy would be including alleged theft when a patient accuses a staff nurse of taking a valuable from the home, a situation not encountered and therefore not addressed in a hospital policy.
Pitfall 3. Failure to track infection adequately so trends can be effectively monitored and addressed.
The Joint Commission requires that you monitor and improve upon infection control trends, but completing infection control log forms and submitting them to the hospital's infection control practitioner is not enough to comply," says Friedman. Even after the forms have been turned in, Friedman looks for the following information on surveys:
* the number of infections for both patients and staff;
* the types of infections;
* if possible, the source of the infections (ex. home care agency acquired or community acquired).
When incident reports are completed by the home care department and submitted to the hospital's risk management staff, the final report should identify types of incidents or accidents specifically for the home care program, so the agency can monitor for patterns and trends, says Friedman.
When areas of concern are pinpointed through the feedback, Friedman expects action on the agency's part.
"If the home care organization identifies a pattern or trend, I would look to see that there was follow-up action taken to correct the problem that was identified -- that they did something about it to prevent that pattern or trend from continuing," says Friedman.
Murphy uses the following client as a prime example of acceptable follow-up: One home health agency noticed a trend of increased wound infections over several months. The agency established an educational wound care clinic for its home care nurses, during which staff's sterile techniques were checked. There was an immediate decrease in wound infections following the clinic.
Pitfall 4. Not getting orders signed by physicians in a timely fashion.
Getting physician orders signed quickly has long been a trouble spot for home care agencies," says Debbie Payne, RN, BSN, CRRN, associate director in the Joint Commission's department of standards interpretation. While it's the agencies that suffer the consequences, she says the problem is often based elsewhere.
"Sometimes it's the physicians who need education about what's required by laws and regulations in terms of them getting orders signed and back to the organization," notes Payne.
That's not to say there aren't steps you can take to improve compliance.
* Look at the entire process.
Payne points out that many agencies fail to review their process for tracking orders from start to finish.
"I don't think it has to be anything extensive," she says of the review. "Our standards require organizations to have policies and procedures that spell out the responsibilities of physicians providing services to patients."
* Be specific when setting physicians' requirements.
Written procedures must specifically state physician responsibilities for returning orders in a timely fashion.
"Simply defining in writing the policies regarding a doctor's and agency's responsibilities may be the solution," Murphy says. A good policy, for example, would specifically outline to physicians that forms must be signed and returned within 30 days. A bad policy would require forms to be signed and returned "in a timely fashion."
Many organizations simply attach the written policy to orders when delivering them to physicians, according to Payne. This can be particularly effective for new physicians just starting to receive orders.
"They're informing the physician of not only what is needed but of what can be expected from the organization, so it's a two-way relationship," says Payne.
* Have a contingency plan for orders not returned.
Policies for physicians' orders should also include what follow-up the agency takes when an order is not returned within the established time frame, according to Friedman. Examples would be calling a physician directly or even sending a fax as a reminder.
The frequency of sending out the written policy can vary. Payne notes that some home care agencies make a point of addressing physician responsibilities when applicable during any staff meetings with the hospital to remind the physicians of their requirements regarding orders.
Unfortunately, reminders are often not enough," says Christy Murphy , MHA, executive director, Lucy Lee Hospital Home Health and Hospice Services in Poplar Bluff, MO.
"We know who the prime offenders are, and we try to set aside a specific time each week to call the physician and say 'Hi, let me tell you about Mrs. Smith and Mr. Brown. By the way, could you sign this please?'"
Pitfall 5. Having nonstandardized documentation open to surveyor subjectivity.
The Joint Commission standards often spell out what the end result must be but not how an agency reaches the end result. For instance, for continuum of care and examples of evidence of performance, a score of 1 (the best score) is given when "the organization's entry process is clearly and fully defined and implemented. One surveyor's criteria for "clearly and fully defined and implemented could be entirely different from what another surveyor would require.
Don't blame the surveyors
Murphy says subjectivity is a problem regardless of what specific standard you're talking about; however, the subjectivity isn't necessarily the fault of the surveyors. Uniformity among organizations should fall on the shoulders of the agencies.
"If everyone used the same forms, surveyors wouldn't have to spend so much time digging for information," she says.
For standardized record keeping, Murphy suggests using the minimum data and basic element requirements of Medicare as a starting point.
She adds that communication during a survey is critical to avoiding the same problem in the future. When a surveyor makes a suggestion, be sure to pass it on to affected parties, particularly physicians. "We try to communicate anything that affects physicians to them immediately to make them think we have their best interests at heart," she says. *
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