JCAHO snoops in your private duty business
Problems involve documentation, supervision
What are Joint Commission on Accreditation of Healthcare Organizations surveyors looking for when they turn their attention toward your private duty business? Here are some of the standards that normally trip up agencies with private duty services:
• Standard TX1.2
The actions taken by the personal care staff do not match the interventions identified on the plan of care.
"In reviewing the records, frequently the aide documentation does not match the plan of care," says Mary Friedman, RN, MS, CRNI, a consultant with Home Health Systems in Marietta, GA. "This is a common problem for aide services."
For example, the plan of care says the patient is supposed to receive a bed bath, and the aide instead gets the patient up for a shower because the patient says he or she is feeling well. Or the nurse checks off that the aide is supposed to perform range-of-motion exercises, and then the aide does not check off that he or she has done them.
• Standard TX2
The physician’s orders are not signed within the time frame required by the organization.
The designated time frame varies according to state licensure regulations. Because physician’s orders are not required by some states for private duty home health aide/homemaker services, generally this standard is a more of a problem for the skilled services, such as those that employ RNs or LPNs.
• Standard HR6
The private duty organization has not defined the skills that must be observed for an RN or an LPN.
"This is a competence assessment that is usually documented in the staff member’s personnel record on a form that’s developed by the agency," says Friedman.
And don’t forget contract staff, either, advises Betty Dixon, RN, BSN, a home care consultant in Savannah, GA. "If an agency provides contract services, then the Joint Commission reserves the right to evaluate the agency’s assessment and the quality of services provided under the contractual arrangements. So if you have contract staff, you need to look at their contract; their competency; their orientation to your mission, vision, and values; and their ability to represent your company in the best light and provide good quality patient care."
• Standard IC2.1
There is a lack of understanding of the kinds of infections that need to be reported for both patients and staff. Also, when the infections are identified, they are not reported back to the organization.
Surveyors find that the infections are reported to the physician and are followed up medically, but they are not reported back to the organization for tracking, Friedman says.
Infection control is a big issue, adds Dixon. "The Joint Commission is looking to see that people are washing their hands before and after delivery of service. This feeds into our national concern that we are beginning to develop some medication-resistant strands of bacteria. When patients leave the hospital, they may be carrying the bacteria out to the community. The Joint Commission then says to its surveyors, Since we are the watchdog of this home care organization, we need to make sure that these nurses, aides, and therapists are providing care and practices that are going to decrease the risk of infection to the public at large.’"
The Joint Commission looks at the agency’s infection control policies and procedures, how it tracks infections, and what it does about the infections it has identified, Dixon says. Staff need to be aware of the agency’s infection control policies and procedures and follow them. "If your agency says it uses gloves, you need to use gloves. If the policy doesn’t address gloves, then it’s optional. But you have to wash your hands in the time period between taking the dirty dressing off and putting the clean dressing on."
• Standard HR3.2
Not all shifts are being supervised.
Sometimes the night shifts are not supervised in the same manner as the day ones. Find out through interviews with the clinical staff and by looking at the documentation in the clinical record.
Organizations should give themselves plenty of time to prepare for the Joint Commission survey and possibly for the staff to attend an educational program on the standards so they learn them and know what they need to do to implement them, Friedman advises. "Also educate the employees about any new policies or forms, or just to make sure that everyone is kept current on the changes within the organization."
[Editor’s note: The Joint Commission has published The 1997-98 Standards for Home Care. The Standards for Home Care is an abridged version of The Comprehensive Accreditation Manual for Home Care that includes home care standards and intent statements in a compact, 6"x 9" format. The publication is $55 (order code HC-105EM), and can be ordered through the Joint Commission’s Customer Service Center at (603) 792-5800.]
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