AHCA Doesn’t Require / Don’t Do It

If it’s in your facility policy you need to be doing it.

When doing Mock surveys and reviewing facility resident files. I often find what I call overkill. Meaning a lot of non-required items such as evaluation forms and questionnaires in the resident files. These items were introduced into their admission packets by individuals whom they used to help them open up their facilities.

These include healthcare questions the resident or family fill out. Questions relating to the residents cognitive status and medical conditions. I also see elopement assessment forms.

The problem is that this paperwork is included in their facility admission package. These items are NOT required. This paperwork often gets filled out by residents or family and filed in the chart without facility review.

Then an 1823 is placed in the chart with conflicting information. The 1823 often will often omit a diagnosis mentioned on the admission medical intake form. I also observe allergies and care levels that contradicts the 1823.

The elopement assessment will identify them as an elopement risk and the 1823 will not or vise versa.
Other issues including issue finding blank assessment forms in the admission paperwork. Remember if you have it in your admission packet and have a policy you need to do it.

My advice is to always to stick to what the regulations require you to have. If you want to do extra steps than you better have a good system in place to double check everything and look for contradicting data. And take the appropriate actions to get the answers as to what is actually correct.

Action Steps

Review at your facility admission paperwork. Look for items that require the individual to provide health information. Determine if you are actually using this information for any functional purpose. If not remove it from your required admission paperwork.

If you are doing any elopement evaluations. Make sure that it is being done and the information matches the 1823. Also review what your policy states as far as reassessment procedures. Make sure the policy is being followed.