The Home Health Audit Form serves as a comprehensive tool for evaluating the quality and compliance of home health services. This form is essential for ensuring that all medical records and care protocols are properly documented and followed. By utilizing this form, healthcare providers can maintain high standards of care and meet regulatory requirements.
To ensure your home health services are up to standard, fill out the form by clicking the button below.
The Home Health Audit form serves as a comprehensive tool designed to ensure that home health care providers meet essential standards and guidelines for patient care. This form includes a series of questions and checklists that cover various aspects of patient admission, care planning, and documentation. Key areas assessed include the timely initiation of care, the completion of necessary physician orders, and the accuracy of medical records. The form also addresses medication management, patient rights, and the presence of required agreements and acknowledgments. Additionally, it evaluates the consistency of care provided with the established plan, the documentation of skilled nursing visits, and the overall coordination of care among different health disciplines. By reviewing these components, the audit aims to promote quality care and compliance with regulatory requirements, ensuring that patients receive appropriate and effective services in their homes.
Home Health Medical Records Audit Form
(Updated for CY2013)
Auditor’s Name/Title: ________________________________________________________
Date: ___________________________
Yes
No
N/A MR #
Comments
Admission
1.Patient Referral Sheet Complete Timely Initiation of Care
Face to Face Encounter Within 90 Days To SOC
Face to Face Encounter Within 30 Days To SOC
History of Physical Present
2.Pre‐Admit Physician Order –
Signed, Dated or VO signed by RN + Physician
3.Primary DX M1020 Secondary M1022 M1022
M1022
Any Codes 401.1 Any Codes 401.9
All DX Supported & Sequenced Properly
4.Medication (N)ew and (C)hanged Interactions – Included Food/OTC
5.Admission consistent with Agency Admission Policies
6.Patient/Client Service Agreement – Signed, Dated & Complete
7.Insurance Screening Form – Signed & Complete
8.Medical Necessity Noted
9.Acknowledgement, Receipt & Explanation of the Items Below:
a.Home Care Patient Rights & Responsibilities
b.Privacy Act Statement‐Health Care Care Records
c.Complaint Procedure
d.Authorization for Use or Disclosure of Health Information (if applicable)
e.Statement of Patient Privacy Rights (OASIS)
f.Consent for Collection & Use of Information (OASIS)
N/A
MR #
g.Emergency Preparedness Plan/Safety Instructions
h.Advance Directives & HHABN
10. Complete Post Evaluation –
D/C Summary Report by RN/PT/OT/ST on:
a. Start of Care
b. Resumption of Care
c. Recertification
Plan of Care 485
11.Plan of Care Signed & Dated by Physician Within 30 Working Days or State Specific days‐ ________
12.Diagnoses Consistent with Care Ordered
13.Orders Current
14. Focus of Care Substantiated
15.Daily Skilled Nurse Visit Frequencies with Indication of End Point
16. Measurable Goals for Each Discipline
17. Tinetti or TUG Completed at SOC
18. Recertification Plan of Care Signed &
Dated Within 30 Days or State Required
Time
19.BiD Insulin Visits Documented with Vision, Musculoskeletal Need, Not Willing/Capable Caregiver. MSW Every Episode
20. Skilled Nurse Consult
Medication Profile Sheet
21.Medication Profile Consistent with the 4 485
22. Medication Profile Updated at
Recertification, ROC, SCIC, Initialed &
Dated
23.Medication Profile Complete with Pharmacy Information
Physician Orders/Change Verbal Orders
24. Change/Verbal Orders Include Disciplines, Goals, Frequencies, Reason for Change, Additional Supplies as Appropriate
25.Change Orders Signed & Dated by Physician Within 30 Working Days
OASIS Assessment Form
26. Complete, Signed & Dated by:
___________________________
27.M2200 Answer Meets the Threshold for a Medicare High Case Mix Group
28. M1020 & M1022 Diagnoses & ICD‐9 are Consistent with the Plan of Care
29.All OASIS Assessments Were Exported Within 30 Days
30. OASIS Recertifications Were Done
Within 5 Days of the End of the Episode
31.All OASIS Were Reviewed for Consistency in Coordination with the Discipline Who Completed the Form
Skilled Nursing Clinical Notes
32. Visit Frequencies & Duration are Consistent with Physician Orders
33.Orders Written for Visit Frequencies/ Treatment Change
34. Homebound Status Supported on Each Visit Note
35.Measurable Goals for Each Discipline with Specific Time Frames
36. Frequency of Visits Appropriate for Patient’s Needs & Interventions Provided
37. Appropriate Missed Visit (MV) Notes
38. Skilled Care Evident on Each Note
39. Evidence of Coordination of Care
40. Every Note Signed & Dated
41. Follows the Plan of Care (485)
42. Weekly Wound Reports are Completed
43. Missed Visit Reports are Completed
44. Pain Assessment Done Every Visit with Intervention (If Applicable)
45.Abnormal Vital Signs Reported to Physician & Case Managers
46. Evidence of Interventions with Abnormal Parameters/Findings
47.Skilled Nurse Discharge Summary/ Instructions Completed
48. LVN Supervisory Visit Every 30 Days by Registered Nurse
Certified Home Health Aide
49.Visit Frequencies & Duration Consistent with Physician Orders
50. Personal Care Instructions Documented,
Signed & Dated
51.Personal Care Instructions Modified as Appropriate
52. Notes Consistent with Personal Care Instructions Noted on the CHHA Assignment Sheet Completed by the RN/PT/ST/OT
53.Notes Reflect Supervisor Notification of Patient Complications or Changes
54. Visit Frequencies Appropriate for Patient Needs
55. Each Note Reflects Personal Care Given
56. Supervisory Visits at Least Every 14 Days by RN or PT
57. Every Note Signed & Dated
PT
58. Assessment Includes Evaluation,
Care Plan & Visit Note
59.Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered
60. Visit Frequencies/Duration Consistent with Physician Orders
61.Evidence of Need for Therapy/Social Service
62. Appropriate Missed Visit (MV) Notes
63. Notes Consistent with Physician Orders
64. Evidence of Skilled Service(s) Provided
in Each Note
65.Treatment/Services Provided Consistent with Physician Orders & Care Plan
66. Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes
67.Specific Evaluation & “TREAT” Orders Prior to Care
68. Verbal Orders for “TREAT” Orders Prior to Care
69.Homebound Status Validated in Each Visit Note
70. Notes Reflect Progress Toward Goals
71. Evidence of Discharge Planning
72. Evidence of Therapy Home Exercise
Program
73.Discharge/Transfer Summary Complete with Goals Met/Unmet
74. Assessment & Evaluation performed by Qualified Therapist Every 30 Days
75.Supervision of PTA/OTA at Least Every 2 Weeks
76. Qualified Therapy Visit 13th Visit (11, 12, 13)
77.Qualified Therapy Visit 19th Visit (17, 18, 19)
78. Every Visit Note Signed & Dated
SLP
79.Assessment Includes Evaluation, Care Plan & Visit Note
80. Evaluation Done Within 48 Hours of Referral Physician Order or Date Ordered
81.Visit Frequencies/Duration Consistent with Physician Orders
82. Evidence of Need for Therapy/Social Service
83. Appropriate Missed Visit (MV) Note
84. Notes Consistent with Physician Orders
85.Evidence of Skilled Service(s) Provided in Each Note
86. Treatment/Services Provided Consistent with Physician Orders & Care Plan
87.Notes Reflect Supervisor & Physician Notification of Patient Complications or Changes
88. Homebound Status Validated in Each Visit
Note
89. Notes Reflect Progress Toward Goals
90. Evidence of Discharge Planning
91.Evidence of Therapy Home Exercise Program
92. Discharge/Transfer Summary Complete with Goals Met/Unmet
93.Supervision of PTA/OTA at Least Every 2 Weeks
94. Every Visit Note Signed & Dated
Miscellaneous
95.Progress Summary Completed(30‐45Days) Each Episode Signed & Dated
96. Field Notes are Submitted & Complete
97. Chart in Chronological Order
98. Chart in Order per Agency Policy
99.Patient Name & Medical Records Number on Every Page
100. Physician Orders are Completed/ Updated for Clinical Tests Such as:
a. Coumadin: Protime/INR
b. Hemoglobin A1C
c. CBC, Metabolic Panel, CMP
d. Others: _______________________
101.Communication with Physician Regarding Test Results
Process Measures:
Timely Initiation of Care
Influenza Received
PPV Ever Received
Heart Failure
DM Foot Care & Education
Pain Assessment
Pain Intervention
Depression Assessment
Medication Education
Falls Risk Assessment
Pressure Ulcer Prevention
Pressure Ulcer Risk Assessment
Additional Comments/Recommendations ‐
__________________________________________________________________________________________________
THE FOLLOWING IS APPLICABLE FOR QUARTERLY MEDICAL REVIEW REPORT
REVIEWED AND SIGNED BY THE FOLLOWING DISCIPLINARY REPRESENTATIVE
______________________________________
Registered Nurse
Occupational Therapist (If Applicable)
Physical Therapist (If Applicable)
Speech Language Pathologist (If Applicable)
Medical Director
MSW (If Applicable)
MR # ______________________
The Home Health Audit form is a critical document used to ensure compliance with healthcare standards and practices. Completing this form accurately is essential for maintaining quality care and meeting regulatory requirements. The following steps outline the process for filling out the form effectively.
What is the purpose of the Home Health Audit form?
The Home Health Audit form is designed to evaluate the quality and compliance of home health care services. It ensures that all necessary documentation is complete and that care provided meets regulatory standards. The form assesses various aspects of patient care, including admission processes, care plans, and ongoing assessments.
Who is responsible for completing the Home Health Audit form?
The audit form is typically completed by a designated auditor, who may be a registered nurse, a quality assurance officer, or another qualified individual within the home health agency. This person reviews patient records and documentation to ensure compliance with established standards.
What key areas are evaluated in the audit?
The audit covers several critical areas, including:
What does 'N/A' mean in the context of the audit form?
'N/A' stands for 'Not Applicable.' This designation is used when a particular question or item does not apply to the patient or situation being audited. For example, if a patient does not have a specific diagnosis, the auditor may mark that section as N/A.
How often should the Home Health Audit be conducted?
The frequency of audits can vary based on agency policy and regulatory requirements. Generally, audits are conducted at regular intervals, such as quarterly or annually. Additionally, audits may be performed more frequently if issues are identified or if there are changes in regulations.
What happens if discrepancies are found during the audit?
If discrepancies are identified, the agency must take corrective actions. This may involve revising documentation, retraining staff, or implementing new procedures to ensure compliance. The findings are usually documented, and follow-up audits may be scheduled to verify improvements.
Can the audit form be customized for specific agency needs?
Yes, while the Home Health Audit form provides a standardized framework, agencies can customize it to better fit their specific requirements or regulatory environment. This may involve adding additional items or modifying existing ones to address unique aspects of their operations.
What is the significance of the OASIS assessments in the audit?
The OASIS (Outcome and Assessment Information Set) assessments are critical for measuring patient outcomes and ensuring quality care. They help in documenting patient needs and the effectiveness of services provided. Compliance with OASIS requirements is essential for reimbursement and regulatory adherence.
How can agencies ensure compliance with the audit requirements?
Agencies can ensure compliance by regularly training staff on documentation standards, maintaining accurate records, and conducting internal audits. Establishing a culture of quality and accountability within the agency is vital for meeting audit requirements and improving patient care.
Filling out the Home Health Audit form can be a complex process, and mistakes can lead to significant issues. Here are five common errors that individuals make when completing this important document.
One frequent mistake is failing to ensure that all sections are complete. Each item on the form is essential for a thorough audit. If a section is left blank or marked incorrectly, it can raise red flags during the review process. For example, if the Patient Referral Sheet is not filled out completely, it can lead to questions about the patient's eligibility for services.
Another common error is not providing accurate or timely documentation of physician orders. The form requires that physician orders are signed and dated, yet many individuals overlook this requirement. Missing signatures or dates can delay the initiation of care and create compliance issues. It is vital to double-check that all orders are current and properly documented.
In addition, many people do not consistently document patient goals and progress. The Plan of Care should include measurable goals for each discipline, but these can often be vague or missing altogether. Without clear goals, it becomes challenging to assess whether the patient is making progress or if the care plan needs adjustment.
Another mistake involves the lack of coordination between disciplines. The audit form emphasizes the importance of consistency in care. If the OASIS assessments are not reviewed for coordination with the discipline that completed the form, discrepancies may arise. This can lead to misunderstandings about the patient's needs and the effectiveness of the care provided.
Lastly, individuals often neglect to ensure that all documentation is signed and dated. Each note must reflect the care provided and should be signed by the appropriate personnel. Missing signatures can create confusion and may suggest a lack of accountability. This oversight can have serious implications for patient care and compliance.
The Home Health Audit form serves as a critical tool for ensuring compliance and quality of care in home health services. Alongside this form, several other documents are commonly utilized to provide a comprehensive overview of patient care, treatment plans, and regulatory compliance. Each of these documents plays a vital role in maintaining the integrity of home health services and ensuring that patient needs are met effectively.
These documents, when used in conjunction with the Home Health Audit form, create a robust framework for delivering high-quality home health care. They ensure that patient needs are met while adhering to regulatory standards and best practices in the industry.
The Home Health Audit form shares similarities with several other important documents used in the healthcare field. Each of these documents serves a unique purpose while ensuring compliance and quality care. Here’s a look at five documents that resemble the Home Health Audit form:
When filling out the Home Health Audit form, attention to detail is crucial. Here are some important dos and don'ts to keep in mind:
Misconceptions about the Home Health Audit form can lead to confusion and inefficiencies. Here are seven common misunderstandings:
Filling out and using the Home Health Audit form is essential for ensuring compliance and quality of care. Here are some key takeaways to keep in mind:
By keeping these takeaways in mind, you can enhance the quality of care provided to patients and ensure that your agency meets regulatory requirements effectively.