One More Reason to Document

It isn’t as though most agencies need more reasons to document but I found one more at an unexpected survey this week.

My client, Intensive Home Health Care in Vidalia, Louisiana was still up in the air about whether or not to continue JCAHO accreditation. No application had been filed and no payment was made and the agency had just moved locations last week. Imagine our surprise when a JCAHO surveyor walked in for the triennial survey. Oops.

It was an even bigger surprise when the agency without any specific JCAHO survey preparation did very well on survey.

When it came to clinical documentation, the surveyor noted that on the two charts she looked at for home visits had all the skills from the care plan documented accurately, she really didn’t see the need to look further. Go, Rachel! It was Rachel’s charts that were randomly chosen for review. It may have been the first survey that I have ever been a part of where clinical records did not pose a big issue.

On the flip side, one of the nurses during a home visit didn’t wash her hands quite as often as the surveyor would have liked. This is not to say that the nurse did not wash her hands often and thoroughly. However, at one point, the nurse decided to change gloves and neglected to wash her hands as the CDC recommends. Note, this agency has a very low infection rate and there was no prior indication that infection control guidelines weren’t being followed.

So after a week of surveys last week, I have only two pieces of advice. First – wash your hands incessantly much the same way as Lady McBeth is reported to do. Choose either the CDC or WHO hand hygiene (fancy way of saying hand washing) guidelines and educate your staff on them. Secondly, if you pay attention to your documentation now, it will be a most wonderful surprise at survey time when clinical records are not an issue.

Congratulations to Intensive Home Healthcare!