Free Home Health Agency Clinical Record Review-F-62680 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62680 (Rev. 04/09)

STATE OF WISCONSIN DHS 133, Wis. Admin. Code Page 1 of 3

HOME HEALTH AGENCY CLINICAL RECORD REVIEW
Name ­ Patient Start of Care Patient ID Number

Date of Review

Surveyor Number

Agency License Number

Pay Source

Open
Tag DHS 133 Regulation Yes No

Closed
NA

141 149 150 152 153 154 155 156 157 158 159 160 161 162 168 169 231 237 238 239 240 241 242 243 244 245 246

.08(2)(a) .08(3) .09 .09(2) .09(3)(a)1. .09(3)(a)2.a .09(3)(a)2.b .09(3)(a)3.a .09(3)(a)3.b .09(3)(a)3.c. .09(3)(a)4. .09(3)(a)5.a .09(3)(a)5.b .09(3)(b) .11 .12 .21 .21(5)(a) .21(5)(b) .21(5)(c) .21(5)(d) .21(5)(e) .21(5)(f) .21(5)(g) .21(5)(h) .21(5)(i) .21(6)

Patient Rights ­ Written acknowledgement of acceptance. * Waived for federally certified agencies. Complaint Form F-62069 ACCEPTANCE AND DISCHARGE SERVICE AGREEMENT - Signed with services, fees, and charges identified DISCHARGE OF PATIENT ­ Written Notice Non-payment Unable to provide care Staff safety compromised Physician orders discharge No longer needs home health care Copy in patient record Reason for discharge Patient right to file complaint Discharge summary within 30 days REFERRALS ­ Appropriate referrals made COORDINATION WITH OTHER PROVIDERS Conferences with other agency providers Appropriate referrals made MEDICAL RECORDS CONTENT ­ Record must include the following: Patient ID information Appropriate (hospital) information Patient evaluation and assessment Plan of Care Physician orders Medication list and patient instructions Progress notes with services, condition, and progress Summaries of review of Plan of Care Discharge summary within 30 days Form of entries Entries are legible. Entries are permanently recorded. Entries are authenticated with name and title.

.20 224 225 226 227 229 .20(1) .20(2)(a) .20(2)(b) .20(3) .20(4)

PLAN OF CARE Requirement: Plan developed within 72 hours in consultation with physician, patient, and contractual providers. Plan signed within 20 working days Contents: Goals Measurable ­ time specific with benchmark dates Plan of Care complete and accurate (includes Methods / Discipline) Review of plan ­ MD review at least every 60 days MD notified of changes in condition Physician Orders - Drugs and treatments provided per order T.O. signed by MD within 20 days

F-62680 (Rev. 04/09) Tag DHS 133 Regulation Yes

Page 2 of 3 No NA

.14(2) 172 173 174 175 176 .14(2)(a) .14(2)(b) .14(2)(c) .14(2)(d) .14(2)(e)

SKILLED NURSING Made initial evaluation visit with complete assessment Re-evaluations patient needs Initiates POT and revisions Provides services requiring specialized care Initiates preventative and rehab procedures

177 178 179 180 181 184 183

.14(2)(f) .14(2)(g) .14(2)(h) .14(2)(i) .14(2)(j) .14(5) .14(4) .17 .17(1) .17(2)(h) .17(2)(i) .17(2)(a-g) .17(3) .18 .18(1)

192 200 201 193-199 202

214

Clinical / progress notes present Reports changes to MD Arranges for counseling Participates in in-service programs for agency staff Supervises and teaches other personnel COORDINATION OF SERVICE Communication with other disciplines PRACTICAL NURSING ­ Duties clearly delegated Supervision evident HOME HEALTH AIDE SERVICES / PCW Services given in accordance with POT DUTIES - Reports changes in condition Completes appropriate records Duties performed as assigned ASSIGNMENTS - Written instructions per RN / therapist Updates at least every 60 days SUPERVISORY VISITS Evaluation every 60 days PT ST
133.15(4) T189
N/A Yes No N/A Yes

OP
133.15(3) T188
No N/A Yes

MSW
133.16 T191
No N/A

THERAPY
Yes

133.15(2) T187
No

Evaluation and therapy plan developed in consultation with physician. Coordination between RN, therapist, MSW. Progress note after each visit. Summary report and recertification every 60 days.

T TAG

COMMENTS

F-62680 (Rev. 04/09) T TAG COMMENTS

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