The following is a list of the top 10 CHAP deficiencies cited during 2014 surveys. Listed with the standard description is the number of your policy(s) that supports compliance with the CHAP standard.
Our goal with providing you with this information is to give you an additional edge for your survey.
CHAP Standard: Description of standard and policy
CII.7i : The organization demonstrates compliance with TB exposure control plan (policy #5.30).
HHII.7a: C omprehensive assessment includes a review of all current medications, including over-the-counter (OTC)
medications and nutrition supplements (policy #2.53)
HHII.5h: Orders are signed by the physician within time frames established by state/federal regulations and organizational
policy, but at least within 30 days (policy #2.21).
HHII.5k: A copy of the record or abstract is sent with the client if the client is transferred to another facility (policy #2.17).
CIII.1g: Evidence of employee information is maintained in accordance with organization policy and regulatory guides
(policy #4.9).
CII.7n: The organization demonstrates compliance with its Infection Control policies and procedures (site visits to observe
hand washing and bag technique).
HHII.5j: Client summary reports are sent to the physician at least every 60 days (policy #2.25 and 2.37).
HHII.8c: The clinical record documentation provides client information specific to care and services provided (not provided,
current client status, and progress toward goals and outcomes of care (policy #2.7, 2.8 and 2.9).
HHII.5n: Care plans are available for each client receiving Home Health Aide services (policy #2.11 and 2.51).
CII.7g: Education and training programs ensure that new employee orientation addresses all aspects of the Exposure
Control Plan and annual training is completed (policy # 5.4 and 5.5).
Rhonda Surgnier RN CMC
Clinical Director