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Documentation Challenges When Providing Care While Operating Under an Emergency Operations Plan (OME)

When an organization is operating under their Emergency Operations Plan (EOP) what patient care documentation and related processes are required by the standards ?

Any examples are for illustrative purposes only and is not intended to address every possible scenario.

The Joint Commission standards only define 'when' written documentation is required as evidence of compliance. Unless specifically required by the language of an Element of Performance (EP), or law and regulation, the type, amount, frequency, format and location of such documentation is determined by the individual organization. Therefore, organizations may modify policy-driven documentation requirements and format, as needed, under emergency conditions when resources are limited.   

The 'Requiring Written Documentation (RWD)' chapter of the accreditation manual lists those EPs which require some form of written documentation.  Note that compliance with a number of accreditation requirements is determined by the presence or absence of a 'process'. Documentation is but one of a number of ways an organization can demonstrate compliance when documentation is not specifically required by the EP.

For organizations that use Joint Commission accreditation for deemed status purposes, CMS requires that the medical record contain information to justify admission and continued care, support the diagnosis, describe the patient's progress and response to medications and services. However, CMS has issued waivers relaxing some of the documentation requirements during the COVID-19 emergency and are outlined below. 

Assessments and Reassessment
Each organization defines the scope and content of screenings, assessments and reassessments and how such activities are documented in the medical record. During an emergency, documentation requirements – including timeliness of entries - may be modified to meet their capabilities and needs. When temporary modifications are made, entries should remain sufficient to ensure that safety, quality and continuity of care within and across disciplines is maintained.  Consider the following:
Assessments and the frequency performed are determined by the needs of the individual patient and organizational policy. The organization determines what data needs to be collected during the assessment and reassessment processes.
  • CMS has extended the 5-day completion requirement for the comprehensive assessment to 30 days for home health.
  • CMS is allowing HHAs to perform Medicare-covered initial assessments and determine patients' homebound status remotely or by record review.
  • Hospices must continue to complete the required assessments and updates, however, per CMS the timeframes for updating the assessment may be extended from 15 to 21 days.
Similar to assessments, screenings (which can lead to more in-depth assessments) are completed based on the presenting complaint/diagnosis. For example:
  • Nutritional screening - Such screenings are performed to determine if nutritional deficits exist that may require a more in-depth assessment. If such a screening does not reveal a nutritional deficit, a more in-depth assessment is not required.
  • Learning Needs Assessment/Patient Education - Such assessments allow the organization to determine what education may be required so the patient/family can continue care following discharge.  Such assessments and education are processes; therefore, the organization determines what documentation is required. 
  • Medication administration -  Documentation of medication administration, actions taken, and their outcomes are essential for planning and delivering future care of the patient. The organization determines how this information is entered into the medical record. Medication orders are to be written in a manner that provides adequate guidance for safe administration and aligns with the therapeutic goals. 
Reporting - CMS has provided relief to home health agencies on the timeframes related to OASIS Transmission through the following actions below: 
  • Extending the 5-day completion requirement for the comprehensive assessment to 30 days. 
  • Waiving the 30-day OASIS submission requirement. Delayed submission is permitted during the public health emergency
Organizations that use Joint Commission accreditation for deemed status purposes should monitor the CMS website as waivers are being approved frequently and may include state-specific waivers. Click here to access the CMS website.

Additional Resources
Coronavirus (COVID-19) Guidance and Resources
Manual: Home Care
Chapter: Record of Care Treatment and Services RC
Last reviewed by Standards Interpretation: April 27, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: April 13, 2020 This Standards FAQ was first published on this date.
This page was last updated on April 27, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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