Q: How can my staff better address plan of care deficiencies?

Plan of care deficiencies have long been at the top of the list of state and federal surveys. At this time, two accrediting organizations-Accreditation Commission for Health Care and Community Health Accreditation Program, list 484.60(a)(2) as their #1 cited deficiency. The Condition of Participation (COP) 484.60(a)(2) states the individualized plan of care must include: (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the home health agency and the patient. I will be addressing measurable outcomes and goals, which are also mentioned in other sections of the COP, including 484.60(a)(1) that states patient-specific goals must be individualized to the patient based on the patient's medical diagnosis, physician's orders, comprehensive assessment, and patient input. Progress toward achieving the goals is evaluated through measurable outcomes.

Your goals need to be SMART:

Specific-Goal is direct, detailed, and meaningful

Measurable-Goal is quantifiable to track progress

Achievable-Goal is realistic

Relevant-Goal will improve or stabilize health condition

Time Specific-Goal has a deadline

Examples of goals set by the patient:

I want to feel better and walk with a walker.

I want to get my strength back to where I was before I got sick.

I want to be able to walk to my mailbox.

I don't want to go back to the hospital.

Patient-specific goals that are SMART:

I want to go back to living independently in my own home within the next 2 months.

I will be able to use my walker, without my daughters' help to get to the bathroom, bedroom, living room, and kitchen at least 3 times a day within the next 2 months.

Goals are to be set so that any nurse or therapist seeing the patient can determine if they are achieving or not achieving the goal, and that any reviewer reading your notes and comparing with the plan of care can also make this determination.

Examples of nonmeasurable goals include:

Wound to coccyx will improve.

Patient will attain/maintain optimal level of functioning within a month.

Patient will have adequate nutrition, hydration, and elimination by end of certification period.

Blood glucose reading will be within normal limits within a month.

Pneumonia will clear in 2 to 4 weeks.

No signs of increased depression through end of certification period.

Improved mobility by end of certification period.

Examples of measurable goals include:

Wound to coccyx will show healing as evidenced by decrease in size by .2 cm in 30 days.

Improve strength-bilateral upper extremities by 1/2 grade for increased mobility; short-term goal, 5 weeks.

Improve strength-bilateral upper extremities by 1 grade for increased mobility; long-term goal, 9 weeks.

Blood glucose within normal limits; fasting blood glucose 80-120 through end of certification period.

Pneumonia cleared as evidenced by lungs clear to auscultation, decreased SOA and oxygen saturation above 94% in 2 weeks.

No signs of increased depression as evidenced by no changes in Cymbalta required and no feelings of depression stated by patient through end of cert period.

Improved mobility-no calls to 911 due to falls through end of cert period.

Remember to be SMART about the goals that are set by and for each patient.