Home Health Audit Template

Guidelines on Filling in Home Health Audit

Filling out the Home Health Audit Form is a crucial step for ensuring comprehensive review and compliance in home health care services. The form is designed to capture essential information regarding the audit of medical records for patients receiving home health care. Following the steps outlined will ensure that the audit is thorough and that all necessary aspects of care and documentation are reviewed. The process involves checking for proper documentation, adherence to agency policies, and verifying the consistency and accuracy of medical records.

1. Enter the Auditor’s Name/Title and the Date of the audit at the top of the form.
2. For the Admission section, review each item and check “Yes,” “No,” or “N/A” based on whether the criteria is met. Make sure to include the medical record number (MR #) and any comments as necessary.
3. Look at the Pre-Admit Physician Order to verify if it’s signed, dated, or if a verbal order (VO) is signed by both the RN and the physician. Again, mark appropriately and document any observations.
4. Examine the primary and secondary diagnoses (M1020, M1022), noting any codes specifically mentioned in the form (e.g., 401.1, 401.9), and ensure all diagnoses are supported and sequenced properly.
5. Review medication information for new (N) and changed (C) interactions, including food and over-the-counter medications, to ensure they are included.
6. Verify that the admission is consistent with agency admission policies and that the patient/client service agreement and insurance screening form are signed, dated, and complete.
7. Check for documentation of medical necessity and acknowledgment, receipt, and explanation of various patient rights, privacy acts, and complaint procedures.
8. Under the Complete Post Evaluation section, ensure that the D/C (discharge) Summary Report by RN/PT/OT/ST is completed as outlined.
9. Confirm that the Plan of Care is signed and dated by a physician within the required timeframe and matches the diagnoses listed.
10. Proceed through each section (e.g., OASIS Assessment, Skilled Nursing Clinical Notes, Certified Home Health Aide, PT, SLP, Miscellaneous) reviewing and marking each item based on compliance.
11. For all sections, ensure that every applicable field is reviewed for completion, consistency with physician orders, documentation of skilled care, and adherence to home health policies.
12. Sign and date the bottom of the form to certify the completion of the audit.

After filling out the Home Health Audit Form, it is essential to review the findings for any areas of non-compliance or areas for improvement. This review will guide the necessary steps to enhance the quality of care, ensure adherence to policies, and maintain compliance with health care standards. Based on the outcomes, action plans may be developed to address any deficiencies identified during the audit process.

When completing the Home Health Audit form, individuals often encounter several common pitfalls that can lead to inaccuracies and potential issues with the audit process. Recognizing and avoiding these mistakes is crucial for ensuring a thorough and accurate review of home health care services.

1. Failing to completely fill out the auditor's name and title and the date at the top of the form, which is essential for identifying who conducted the audit and when it was performed.
2. Overlooking or incorrectly marking the "Yes," "No," or "N/A" options throughout the document, leading to incomplete or inaccurate assessment records.
3. Not paying close attention to the MR (Medical Record) number and comments sections, which are critical for recording specific details or concerns related to each audit item.
4. Omitting the patient referral sheet confirmation, which verifies timely initiation of care and compliance with face-to-face encounter requirements.
5. Forgetting to ensure that pre-admit physician orders are correctly signed, dated, or verbally authorized (when applicable) by a registered nurse plus the physician, compromising the validity of the orders.
6. Ignoring the detailed requirements for medication profiles, such as properly documenting new (N) and changed (C) medications, as well as potential food and over-the-counter drug interactions.
7. Overlooking patient/client service agreement signatures and completion, which is important for legal and procedural compliance.
8. Neglecting to update or provide comprehensive acknowledgement and receipts concerning patient rights, privacy act statements, and other important informational documents.

Keeping an eye out for these common errors can significantly improve the quality and reliability of the audit process, ensuring that home health care services are accurately evaluated and documented according to the required standards.

When conducting a home health audit, auditors rely on multiple forms and documents to thoroughly review and assess the care provided to patients. These documents are pivotal in ensuring that home health agencies adhere to regulatory standards and provide high-quality care. Below is a list of five essential documents often used in conjunction with the Home Health Audit form.

• Patient Admission Packet: This dossier includes all paperwork completed at the time of patient admission, such as consent forms, insurance verifications, and initial assessments. It’s pivotal for establishing the basis of care and financial arrangements.
• Physician Orders: This document contains all current and past orders from physicians regarding patient care, including medications, treatments, and frequency of visits. Ensuring that these orders are up-to-date and followed is crucial for compliance and quality of care.
• Care Plan: Often referred to as Form 485, the care plan outlines the services and goals for a patient’s treatment. It is signed by the attending physician and should be aligned with the patient's diagnosis and needs.
• OASIS Assessments: The Outcome and Assessment Information Set (OASIS) is a group of standard data elements used to assess the home health care patient’s condition and determine the care required. Complete and timely OASIS documentation is essential for compliance and payment.
• Medication Administration Records (MAR): This comprehensive record tracks all medications administered to the patient, including dosages, times, and any changes. Accuracy in the MAR is vital for patient safety and to prevent medication errors.

Together with the Home Health Medical Records Audit Form, these documents create a comprehensive overview of the patient’s care journey within a home health setting. They are instrumental for audits, serving as the foundation for assessing the adequacy and quality of care provided. By meticulously reviewing each document, auditors can ensure regulatory compliance, identify areas for improvement, and ultimately contribute to the enhancement of patient care standards.

• Medical Record Audit Tool: Similar to the Home Health Audit form, a generic Medical Record Audit Tool evaluates the completeness and appropriateness of medical records documentation. Both tools check for critical elements like proper documentation of diagnoses, treatment plans, and medication management.

• Hospital Compliance Audit Checklist: This document is similar to the Home Health Audit form in that it assesses compliance with regulatory and internal policy requirements. Both involve detailed checks for adherence to standards in patient care documentation and privacy protocols.

• OASIS (Outcome and Assessment Information Set) Assessment Form: Directly referenced within the Home Health Audit form, OASIS assessments are similar as they specifically focus on the consistent, accurate documentation of patient assessments and care plans in home health settings.

• Skilled Nursing Facility (SNF) Audit Form: Similar to Home Health Audit forms, SNF Audit Forms evaluate the quality and appropriateness of care as well as the documentation in skilled nursing facilities, covering areas like medication management and care planning.

• Home Care Licensure Audit Checklist: This checklist parallels the Home Health Audit form in scrutinizing operational and clinical practices against state-specific home care licensure requirements, including patient rights, safety, and care documentation.

• Quality Assurance/Performance Improvement (QAPI) Program Audit Tool: Similar in intent to the Home Health Audit form, this tool is used in healthcare settings to systematically review and improve the quality and safety of patient care, including effectiveness, documentation practices, and regulatory compliance.

• Medication Management Audit Tool: This tool, while focused specifically on medication practices, overlaps with the Home Health Audit form in areas like medication reconciliation, documentation of new and changed medications, and identification of possible drug interactions.

• Patient Safety Audit Checklist: Similar to aspects of the Home Health Audit form, a Patient Safety Audit Checklist focuses on the minimization of risks to patients during care provision, including checks for adherence to safety protocols and emergency preparedness.

• Advance Directive Compliance Checklist: This checklist ensures that providers respect and document patients’ wishes regarding their care, an aspect that aligns with sections of the Home Health Audit form which review documentation related to advance directives and patient rights.

• Care Coordination Audit Tool: Similar to the Home Health Audit form, Care Coordination Audit Tools assess how effectively healthcare providers communicate and coordinate, particularly in planning, documentation, and transitioning of care, ensuring that care is patient-centered and meets the comprehensive needs.

When filling out the Home Health Audit form, some practices can ensure the process is both efficient and effective. Adhering to the following guidelines will not only streamline the audit but also enhance the accuracy and reliability of the information recorded.

• Verify all patient information: Ensure the patient's name, medical record number, and any other unique identifiers are correctly filled in on every page of the form to prevent any mix-ups or discrepancies.
• Review physician orders for completeness: Make sure that all physician orders, including verbal orders, are signed and dated within the required timeframe. This includes checking for the physician’s signature on the Plan of Care and any change orders.
• Ensure accurate documentation: Verify that all services provided are documented accurately, including visit frequencies, duration, and skilled services provided. This should be consistent with the physician's orders and the plan of care.
• Update and sign documentation timely: Ensure all assessments, including OASIS, Plan of Care, and medication profiles, are completed, updated at the required times, and appropriately signed and dated.

• Overlook required signatures: Avoid the common mistake of submitting the form with missing signatures and dates. Each section that requires a signature or a date should be thoroughly checked for completion.
• Ignore inconsistencies: Do not disregard discrepancies between the care provided and the physician’s orders or the Plan of Care. Any inconsistencies should be addressed and corrected in the documentation.
• Miss documenting verbal orders: Never fail to document verbal orders, including the disciplines involved, goals, frequencies, reason for the change, and any additional supplies needed. They must be signed and dated by the physician within 30 working days.
• Assume accuracy: Do not assume all entries made by others are accurate. It's essential to review all sections, including the medical necessity, patient rights acknowledgements, and emergency preparedness plans, for completeness and accuracy.

There are several misconceptions about the Home Health Medical Records Audit that can obscure its purpose and process. Gaining clarity on these issues can help healthcare providers ensure they are meeting necessary requirements efficiently and effectively.

• Misconception 1: The audit process is only about finding faults.
  

  Contrary to what some may believe, the audit is not solely focused on pinpointing errors within home health records. Its primary aim is to ensure the quality and safety of patient care by verifying that all required documentation is accurate and complete. This process helps in identifying areas for improvement and ensuring compliance with healthcare standards.

• Misconception 2: All sections of the audit form must apply to every patient.
  

  The form includes sections that may be marked "N/A," indicating that not all items are applicable to every patient situation. This recognizes the diversity in patient needs and services provided.

• Misconception 3: The form is only concerned with medical documentation.
  

  While medical documentation is a significant focus of the audit, the form also covers administrative and procedural elements such as patient rights, privacy acts, complaint procedures, and insurance screenings. These aspects are critical in delivering comprehensive patient care and ensuring legal compliance.

• Misconception 4: Verbal orders are not permitted.
  

  The form allows for verbal orders, provided they are signed by both the RN and the physician. This accommodates the realities of healthcare provision where immediate decisions can be necessary for patient care.

• Misconception 5: The medication profile only needs to list current medications.
  

  Medication profiles must be comprehensive, including new (N), changed (C) medications, and interactions with food or over-the-counter items. This ensures a holistic view of the patient's medication management is considered.

• Misconception 6: Admission policies do not need to be consistent.
  

  Admissions must always be consistent with the agency's admission policies. This ensures that the agency operates within its defined scope and standards of care.

• Misconception 7: Patient and caregiver education are not audit focuses.
  

  Educational components such as emergency preparedness, advance directives, and patient rights are integral parts of the audit. Educating patients and caregivers is vital in empowering them and ensuring informed decisions about care.

• Misconception 8: Frequency of visits is based solely on agency discretion.
  

  The audit checks for the justification of visit frequencies to ensure they meet the patient's needs and are authorized by a physician. This prevents over- or under-servicing patients.

• Misconception 9: Documentation of skilled care and coordination of care is optional.
  

  Skilled care documentation and evidence of care coordination are essential components of the audit. They demonstrate that patients are receiving the appropriate level of care and that all care providers are working together towards the patient's health goals.

Understanding these misconceptions can help healthcare providers approach the Home Health Medical Records Audit with a clearer perspective, ensuring that their procedures not only meet regulatory requirements but also serve their patients' best interests.

When completing the Home Health Audit form, it is crucial to provide detailed attention to ensure all areas are covered comprehensively. Here are four key takeaways to consider:

• Ensure the Auditor's Name/Title and Date sections are filled out at the beginning of the document to track the audit's execution properly.
• Verify all sections related to patient admission, including the Patient Referral Sheet, Face to Face Encounter timing, and History of Physical presence, are thoroughly reviewed and marked appropriately (Yes, No, N/A) to reflect the patient's records accurately.
• Pay close attention to the Medication Profile sections to ensure medications are listed correctly, including new (N) and changed (C) interactions, and that the profile is consistent with the plan of care. It's also important to update and initial the medication profile at recertification and when there's a start (SOC) or resumption of care (ROC).
• Review the completion and signing of essential documents such as the Plan of Care, OASIS Assessments, and Skilled Nursing Clinical Notes. Each should be properly dated and indicate alignment with the patient's current health status and care plan. This includes ensuring the Plan of Care is signed by a physician within the required timeframe, and all OASIS Assessments are exported within 30 days.

Adhering to these guidelines will promote a thorough and accurate audit process, essential for maintaining the highest standards of home health care and compliance with regulatory requirements.