Category Archives: Survey Scoops

G 121: Compliance with Accepted Professional Standards

If you think this sounds like a very general category, you’re right! This tag can be used to cite many different types of deficient practices. One way to focus your attention would be to ask yourself: “What would any prudent nurse or therapist do in this situation?”

The surveyors can use this tag to cite failure to follow policies and procedures, insufficient or lack of drug regimen review, inappropriate delegation of tasks, failure to track/trend complaints, and poor or incomplete physical assessments. These are just a few of the ways in which this tag has been cited for our company in 2013. Each of these can, and often are, cited in other tags as well.

The surveyor will look for evidence of poor infection control, poor wound care procedures, and not following physician orders. If the patient is hospitalized, the surveyor will look at clinical documentation to see if we failed to notice signs of an impending problem. The surveyor will also compare the care observed during home visits and the clinical documentation to state practice acts as well as policies, procedures and physician orders.

Article submitted by: Lori Velko, Director of Compliance


Professional Advisory Group/Committee

The Professional Advisory Committee (PAC) is a federal requirement. Many states also have their own requirements that impact the PAC. The PAC membership must include at least one physician and one registered nurse as well as representation for other professional disciplines as appropriate. So if your agency provides OT and PT visits, those disciplines must be represented in the PAC membership. The discipline representation must be “professional” meaning that a PTA, COTA, HHA would not meet the requirements but they can still be part of the committee if you desire.

At least one member of the PAC cannot be an owner or employee of the agency. This requirement could be met by including a vendor, past patient, referral source, etc. It’s important to remember, though, that the PAC discusses sensitive information.

The purpose of the PAC is to provide advice and guidance to the agency on professional and patient issues. The other important function of the PAC is to review and approve policies. The federal regulations list that some policies and state regulations sometimes require additional policies to be included. A PAC meeting format is available on the Girling dashboard. You should also refer to your agency policy for guidance on the PAC.

The PAC is also responsible for evaluating the effectiveness, efficiency, adequacy and appropriateness of the services provided by the local agency.

PAC meetings must occur at least yearly and as needed. Some states may require regular meetings more frequently. Minutes of the meetings must be documented and maintained at the local agency along with a signed attendance sheet.

Article submitted by: Lori Velko, Director of Compliance