Changes to Nursing Notes Per Joint Commission Triennial Survey
By Nufactor - January 20, 2023

We want to share with you the recent outcome of our Joint Commission (TJC) triennial survey related to nursing care. We continue to appreciate you and the care you provide for our patients.

While Nufactor doesn't provide direct hands-on care to patients, the Joint Commission surveys us under the same standards as they do for Home Health Agencies. This is primarily due to Nufactor billing Medicare Part B for a small number of visits (mostly SCIg teach and train visits). Medicare requires us to have deemed status via our TJC survey.

The survey included review of nursing notes, nursing contracts, and 3 "live" visits which were conducted with the surveyor viewing the nurse, patient, and aspects of the visit via FaceTime. Several trends were noted during the survey which will result in the need for changes to process and provision of educational subjects to all our agency partners. We ask you share this information with your nurses so we can address our TJC nursing related findings together.

As described below, some findings prompted changes to the Nufactor Nursing Visit Note (which includes the Medication Profile). If you need an electronic version, please contact a Nufactor Clinical Nurse Coordinator or Clinical Nurse Educator. Nufactor will include a paper version in patient shipments. If you have adapted the Nufactor Nursing Note into your electronic version, please make corresponding changes.

Findings/Corrective Actions:

Finding:

• Medication Profiles – Medication profiles submitted by nurses frequently did not match the medication profile of record. In most cases, the patient advised Nufactor of additional medications they take which were not noted on the profile submitted by the nurse.

Corrective Action:

• Nufactor will modify our current process including revision to our standard nursing note. We will send a current medication profile with each delivery. We will no longer ask the nurse to write in the full profile when the Nufactor medication profile is reviewed. We will ask the nurse to review the Nufactor medication profile and make note of any new medications added or any medications that have been discontinued. See an example of the new note below. If the Nufactor medication profile is not available for review, we ask the nurse to fully list a complete medication profile.

Finding:

• Use of prohibited abbreviations – TJC published a list of prohibited abbreviations several years ago. The abbreviations are those which can be easily mistaken with another (for example, q.d. can be confused with QID) and should not be used to avoid administration errors.

Corrective Action:

• Nufactor will add the list of prohibited abbreviations to the nursing note so nurses are immediately aware of what abbreviations they should NOT use.
  See example of new nursing note below:

Finding:

• Not following Standard Precautions – These were noted during the observed (FaceTime) visits:
• In one instance a nurse intentionally tore the glove to use an ungloved index finger to palpate the vein for an IV start. The glove was not replaced nor was the IV site cleaned a second time before starting the IV.
• In three instances the nurse did not clean the top of the medication vial (following removal of the cap) or the additive port of the normal saline IV bag used for infliximab.

Corrective Action:

• Nufactor will provide educational tools to each agency regarding Standard Precautions, however we ask each agency to remind their staff of the requirement to use intact gloves for any IV start and/or indwelling catheter access.
• Nufactor will update the nursing note to remind the nurse to clean the top of the medication stopper, medication additive port, and/or access device port with an alcohol pad prior to accessing the vial/port. See example of new nursing note section below. Notes:
• Vial stoppers are not sterile and must be sanitized after the lid is removed.
• Always allow vial stoppers/port to naturally dry without wiping, fanning, or blowing.
• Nufactor will randomly request copies of supervisory visits conducted by the agency to determine clinical care competency for staff providing care for Nufactor patients.

Finding:

• Documentation
• Nurses did not document the strength of heparin administered during flushing of the IV catheter.
• Nurses did not document the volume of flush solution administered.
• Nurses did not document if the IV was flushed at the end of the infusion.
• Nurses did not document if the peripheral IV was removed.
• Nurses did not document the lot # and expiration date of the infused medication.

Corrective Action:

• Nufactor will update the nursing note with easy-to-use check boxes for most of these items to allow the nurse to document actions taken during the visit. See example of updated nursing note below.

Finding:

• HR documents required by TJC were not available on request during the survey. Examples include:
• Primary source verification of RN licensure at the time of hire and/or when licensure expires
• Annual TB screening
• Hepatitis B vaccination series or declination of same
• Criminal background checks
• Orientation
• Annual competency
• Annual evaluation
• Job description

Corrective Action:

• At initial credentialing, these documents may be requested for nurses providing care to Nufactor patients.
• At annual recredentialing these documents may be requesting for nurses providing care to Nufactor patients.

Lastly, Nufactor will be adding a quality assurance nurse to our staff. This nurse will review nurses notes for quality. Issues noted will be brought to the attention of the agency with request for corrective action.

We appreciate your willingness to help us continue to provide high level care for our shared patients.

Nufactor Nursing Notes:

Nufactor Nursing Note-MonoclonalAntibody
Nufactor Nursing Note-ImmuneGlobulin
Nufactor Nursing Note-Miscellaneous
Nufactor Nursing Note-Bleeding Disorder