Inservice

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Participants will learn I review:

1.The Clinical Staff Documentation Checklist and the requirements for completion when completing an Assessment

2.The Documentation Checklist used for submitting completed paperwork to the office

3. New CMS requirements for Start of Care Assessments

4. Medication Review and Reconciliation (review)

5. Sixty (60) day summary requirements (review)

6. Supervisory visit (documentation of)

7. Prevention and control of COVID-19 Transmission

8. Review of Hand Hygiene

9. Differentiate between  documentation requirements for each of four different  assessments

• OASIS DOCUMENTATION REVIEW

Diagnoses

• List all relevant diagnoses
• The first 3 diagnoses MUST explain why we are in the home
• If PT/OT are in the home, justifying diagnoses MUST be listed first
• Be sure to list the "Symptom Control Rating" (SCR)#, for each diagnosis
• Select whether or not the diagnosis is an "Onset" (0) or "Exacerbation" (E).
• Review and verify all diagnoses when completing any OASIS to ensure proper and accurate acuity levels are listed. If necessary, list them in the proper acuity order.
• The principal diagnosis which provides information to describe the primary reason for which a patient is receiving home health services

• Functional Limitations I use of any Assistive Devices.
• Nutritional Status
• Diet must be listed and be relevant to the patient's diagnosis(es).
• Activities Permitted
• Safety Measures
• Prognosis

Mental Status

• Identify and record whether or not the patient is oriented (to at least: person, place, and time)

Depression Screening

• ALL patients must be screened for depression using the "PH0-2" Scale

GG0170C- Mobility

• The SOC/ROC Performance Level vs the Discharge Goal Level
• Code these levels with a realistic expectation based on the patient's physical & functional capabilities

Reported Height/Weight

• Be sure to list the height in "inches" and mark both as "reported"

Vital Signs

• Document the A1C level, if available. Please note if it is not available.
• If a vital sign or blood glucose level is abnormal, Re-check it!
• Be sure to document that it was "rechecked" and if there needed to be any intervention.
• If it remains abnormal and is critically "low" or "high" call 911, so the patient can be transported to the ER
• Notify the office immediately of any emergency health situation

Reasons for Homebound Status:

• Must list ALL reasons I conditions that justify the patient's homebound status

Frequency of Planned Visits

• List frequency for ALL disciplines and Start Date for each discipline, if different, from the SOC date.
• Each discipline MUST visit the patient in accordance with the "visit frequency" listed in the Plan of Care Orders.
• If the "visit frequency" changes, for any reason or any period of time, a Physician Order must be completed, with the rationale for the change.
• If a visit is missed, complete a "Missed Visit" Note & Physician Order listing an explanation of the missed visit.

Orders, Showing Appropriate Plan

• ALL Ordered Treatments (e.g. Wound Care, PT, OT, and Teaching) and/or Areas of Teaching, for ALL Disciplines must be reviewed and listed.
• If HHNPCA Services are ordered, list the frequency & duration of services.

Discipline Goals and Discharge Plans:

• Document the expected time period in which the patient goals are expected to be met.

OASIS Updates and/or Corrections

• If an update or correction needs to be made to an OASIS assessment, DO NOT create a "new" one.  EDIT the existing OASIS.
• If a duplicate, or redundant OASIS is created in error, please call the office right away and let Grace/DON know, so that the extra OASIS can be deleted.

Physician "ADD" orders

• A Physician Order should be prepared for ALL OASIS (SOC, RC, ROC,& DS), Discharges from Service, Changes  in Treatment Plan, Medication Changes, Changes to PCA Hours, etc.
• A Physician Order can be generated in Allegheny.
• Please contact the office to have it printed and mailed out to the patient's doctor.

Physician Notification

• The patient's physician needs to be notified IMMEDIATELY of ANY change(s) in the patient's condition.
• Notify the PSHC Nurse Managers as soon as possible.
• Document any changes, as well as whom you notified (and when!) along with the ordered intervention(s).
• A follow-up investigation will need to be completed so it is important that all steps taken are identified.

Changes After the Development of a Plan Of Care

• Prepare an "ADD Order" for any changes after the initial POC
• The patient's doctor must always be kept in "the Loop" and made aware of everything related to the patient.

HHNPCA Plan of Care

(Must be turned in when completing any OASIS):

The HHNPCA Plan of Care needs the following areas:

• Diagnoses/mental Status
• Functional Limitations/Precautions
• Advance Directives
• Personal Care
• Activities
• Housekeeping
• Meals/ Nutrition
• Special Instructions
• Other Services/Additional comments

Change in an Unskilled Patient's Condition

• If a change in an unskilled patient's condition is noted, and it would benefit the patient to receive "Skilled" Services, a Physician Order should be prepared requesting the status change, service type and/or visit frequency.
• A clinical rationale for the request should be included in the Physician Order.