I.  THE 485

YES

NO

N/A

COMMENTS

1.  Is the 485 current and signed by the M.D.?

2.  Is there a date stamped when the 485 was returned?

3.  Are all meds listed with route, dose, frequency, and indicated as new or changed with “n” or “c”?

4.  Are the supplies listed on the 485?

5.  Are the goals specific, measurable, achievable, realistic and timed?

6.  Is there and END IN SIGHT for daily SN visits in field 22 of the 485?

7.  Is there a letter of medical necessity for SN visits 5 times a week or greater?

8.  Was the recert 485 signed and returned before the recert period began?

9.  Is there an EPC code printed on the 485?

1.  Is there an M.D. order for admission and/or recert for home health care?

2.  Is the frequency based on assessment of client’s needs?

3.  Are there signed supplemental orders to reflect any changes to the plan of care?

4.  Is there an order for all support services that are caring for the client?

5.  Are all orders signed/ cosigned by the RN and the Physician?

6.  Are all orders signed timely within 30 days?

7.  Are telephone orders updated with new goals when changes occur in the plan of care?

III  Case Conference

1.  Are there interdisciplinary case conferences in the chart every 60 days?

2.  Is there a date stamped when case conference was sent to physician?

3.  Do the case conferences reflect the status of the patient, plan modalities, summary, and prognosis?

4.  Does the case conference form indicate that the chart was updated / reviewed?

IV.  SAFETY GUIDELINES

1.  Was home safety checklist implemented and completed?

2.  Was safety-teaching guidelines implemented on admission and completed within 2 visits?

V.  NUTRITIONAL SCREENING

 1.  Is the nutritional screening completed on admission and with each recert?

2.  Has a M.D. order been obtained for a dietitian’s evaluation when > 7?

3.  If not, is there an explanation (communication record or visit note) as to why not?

4.  Has the Dietitian been notified (if indicated)?

VI.  NURSING ASSESSMENT/ OASIS/ ADMISSION CRITERIA

1.  Is OASIS completed, signed and dated by nurse doing assessment?

2.   Do the Diagnoses match the 485?

3.  Are there dates of onset or exacerbation with each diagnosis?

4.  Is there an OASIS for each required occurrence, admit, recert, post-hospital, significant change in condition, transfer and discharge?

5.  Does the 485 reflect the assessment?

6.  Does the client meet criteria for admission?

7.  Is there a copy of the INFUSION PATIENT ADMISSIONS AND ACCEPTANCE CRITERIA (if applicable)?

VII.  NURSE’S NOTES

1.  Were the visits made at ordered frequency?

2.  Do the notes reflect the plan of care?

3.  Is each note billable/skilled per orders?

4.  Is the patient and/or caregiver’s response to interventions/teaching noted?

5.  Is Homebound status documented consistently?

6.  Does the homebound status documented agree with the 485?

7.  Are there orders for all skills performed and information taught, etc.

8.  Was the M.D. notified of any change in condition?

 9.  Was the RN manager notified of any change in condition?

10.  If the client receives daily care, does the documentation support it?

11.  Is there coordination of care between services?

12.  Is there documentation of the desired goal on each note, does it relate to goals on 485 and to primary or secondary diagnosis?

13.  Is there documentation of progress or lack of progress towards goals?

14.  Are all medications administered by agency staff charted to include med, time, route, dose, client, effects, and absence of adverse reaction in the nurse’s note?

15.  Are notes legible and written in permanent black ink?

16.  Are corrections done according to agency policy no writeovers?

17.  Do notes contain only agency-approved abbreviations?