NPSGs
All disciplines
What are the 2025 Homecare NPSGs?
Identify patients correctly
Use medicines safely
Prevent infection
Prevent patients from falling
Identify patient safety risks
(Source: TJC Prep Guide 2025)
RN/PT/ST
What are High Alert Medications?
HH/HOS Policy Addendum 3-001.A: HAMP Policy (High Alert Medication Policy)
High Alert Medication Policies Apply in the Following Situations in Home Care:
All opiate/narcotic infusions including patient controlled analgesia (PCA)
All pediatric (age younger than 14 years) intravenous medications and infusions
All insulin injections using concentrations greater than 100 units/mL
RN/LVN
What CLIA waived testing is done in the home setting?
We only perform one, INR.
(Source: TJC Prep Guide 2025, HH/HO PT/INR Competency)
All disciplines
How is the plan of care and visit plan communicated with the patient/caregiver(s)? Whose responsibility is it to inform the patient/caregiver? How is this documented?
Patients/caregivers are informed of the plan of care when each discipline initiates care, using the My Care Plan Form. This can be updated as needed throughout the plan of care.
Patient/caregivers are informed of the visit plan in several ways. At SOC/Eval, the POC is discussed with patient/caregiver, including frequency and duration.
The calendar left in the patient's home is updated by each clinician throughout the POC to reflect the visit plan; this includes involving the patient/caregiver(s).
In addition, at each visit, the next visit plan, including day or day range, is discussed with patient/caregiver(s) and documented in the careplan under the "next visit plan."
(Source: TLH Remote Client User Guide, HH Policy 1-001.1)
RN/LVN/PT/OT/ST/MSW/RD
What is the policy for receiving verbal orders or reporting critical test values?
Policy 2-020: All verbal orders or reporting of critical test results will be “read back” and confirmed by the physician (or other authorized licensed independent practitioner) or designee to ensure accuracy of the order or test result.
Policy Addendum 2-020.A: Verbal Order Read back procedure
Verbal order verification is required for all medication orders and orders for therapeutic agents before action is taken on the order. Verbal order verification will be obtained by recording the verbal order and reading the order back to the ordering physician. The read-back portion of this process must be performed in a direct, live communication with the physician.
All disciplines
What is the policy for documenting missed visits? What is the process when the CHHA has a missed visit?
Policy 2-018: The physician must be notified if a scheduled visit is not completed. The reason for the missed visit and notification of the physician must be documented in the medical record.
CHHA missed visit - CHHA must contact the CHHA RN Supervisor in the office. CHHA RN Supervisor to notify physician/authorizing provider of the missed visit.
All disciplines
Language assistance is a Joint Commission standard and CA Senate Bill 853: What is the difference between an interpreter and a translator? What type of _______ services are available per Kaiser Permanente policy?
Interpreter - interprets spoken language
Translator - translates written language
Interpreter services available are as follows:
QBP - Qualified Bilingual Providers (may speak to patient in patient's own language but may NOT act as an interpreter for another staff member)
QBS - Qualified Bilingual Staff, level 1 or level2
KP Language Connect (Language Line)
Certified Sign Language Interpreter
(Source: TJC Prep Guide 2025)
All disciplines
What is your role in a disaster?
We are assigned a role, and it could change during a disaster.
(Source: TJC Prep Guide 2025, HH Policy 7-001)
All disciplines
What should you do if there are pets in the home? What about firearms?
Intake: Please make sure that patients and families know that firearms and pets need to be secured away from the care area during visits.
Clinicians: Please communicate the presence of pets and firearms to the team and all other clinicians, and remember to screen for changes before each visit. It is important to make sure ALL pets (not just dogs and cats) are secured at all visits, so that we set up our team members for success and follow our policy for the safety of all staff.
(Source: HH/HO Policy 6-012.2)
RN
What signed forms are required when admitting a patient in a facility?
Facility needs to keep a copy of consent and benefit election forms.
When a patient is admitted to hospice and they live in a facility, the SNF Education Form/RCFE Education Form is completed and filed in their record.
(Source: TJC Prep Guide 2025)
SNF patients need a SNF letter of agreement and responsibility grid signed by the SNF charge nurse or DON.
(Source: SNF Toolkit)
RCFE patients need a HIPAA authorization form and a copy of the facility's Hospice Waiver.
(Source: RCFE Toolkit)
All disciplines
NPSG: Identify patients correctly: What two patient identifiers may be used in a single family home?
What two patient identifiers may be used in a multiple patient setting?
The two primary identifiers are:
1. Patient name
2. Patient address
In any situation of continuing one-on-one care where the staff knows the patient, one of the identifiers can be direct facial recognition.
In the case where patient is located in multiple patient setting (Board and Care, ALF) staff will use the identifier of date of birth (DOB) instead of place of address.
(Source: TJC Prep Guide 2025)
RN/LVN/PT/OT/ST
What are the required elements of a complete medication order?
Patient name
Medication name (generic or brand)
Dose
Route
Frequency
Diagnosis, condition, or indication for use
Stop date, if appropriate/applicable
(Source: HH Policy Addendum 2-020.A, HO Policy Addendum 2-045.A)
RN/LVN
What is the policy for disinfecting the INR machine?
Clean after each use per manufacturer guidelines.
(Source: TJC Prep Guide 2025, HH/HO PT/INR Competency)
RN/PT/OT/ST
What are components of a complete oxygen MD order?
Supplemental oxygen (generate order):
Liter flow (no ranges)
Route (e.g. NC, mask)
Frequency
Indication
And other details of the oxygen in comments
Example: Inhale 2 liters per minute via nasal cannula continuously for shortness of breath
Inhale via nasal cannula as needed for shortness of breath: 2 liters per minute for mild symptoms, 3 liters per minute for moderate to severe symptoms
DME (do not generate an order):
Oxygen device (ie. concentrator)
Back up oxygen source (portable O2)
PT/OT
What modalities of care may be provided without a physician's order?
Simple answer - NONE
All modalities require a physician's order (ie ultrasound, continuous passive movement, e-stimulation, ice/heat therapy, therapuetic exercise, TENS, kinesiotaping, etc.)
RN
For patients receiving infusion therapy, how often are IV assessments completed?
IV site must be observed/assessed and documented at each nursing visit. Document assessment in Infusion Assessment
(Source: TLH Home Infusion Therapy Manual)
All disciplines
What must be documented when using interpreter services?
Language Line: Language Line Company and Unique ID# of the interpreter.
Qualified Bilingual Staff: Enter the NUID and QBS level
All disciplines
Does the patient/caregiver know what to do if they need to evacuate?
Yes, patient/caregiver are provided education and told to complete their individualized disaster plan in the Home Health Care Guide or Hospice Care Guide.
(Source: TJC Prep Guide 2025, HH Policy 2-048.1)
All disciplines
What items should you always keep with you for safety?
Your cell phone and your car keys are your lifelines. You always need to be able to call for help and leave unsafe environments. Please keep these items on your person at all times.
All disciplines
How do you communicate pertinent hospice patient information to after-hours staff?
There is a daily watchlist email submitted from the agency to our after-hours team identifying all categories of reporting patient status such as transitioning and actively dying patients.
All disciplines
NPSG: Prevent infection: What guidelines does Kaiser Permanente follow in regards to hand hygiene and what are the "5 moments of hand hygiene?"
The WHO (World Health Organization)
a) Before touching a patient (to initiate patient care)
b) Before clean/aseptic procedures
c) After body fluid exposure/risk
d) After touching a patient (completing patient care)
e) After touching patient surroundings
(Source: TJC Prep Guide 2025)
RN/LVN/PT/OT/ST
Is this medication order correct?
Acetaminophen 325mg
Take 2 - 3 tablets by mouth every 8 hours as needed
What's missing?
Indication
When to take 2 tablets vs 3 tablets
Max dose of all sources of Tylenol in 24 hour period
(Source: HH/HO Policy 3-002, HH Policy Addendum 2-020.A., HO Policy Addendum 2-045.A)
Acetaminophen 325 mg
Take 2 tablets by mouth every 8 hours as needed for mild headache.
Take 3 tablets by mouth every 8 hours as needed for moderate to severe headache.
Do not exceed more than 4000 mg of Acetaminophen in 24 hours from all sources
(3000 mg if patient is on hospice or 75 years or older, 2000 mg if patient has liver problems)
(Source: TJC Prep Guide 2025, TLH Patient Education Guide: Safe Use of Acetaminophen)
RN/LVN
How are you deemed competent to care for an anticoagulation patient and to perform INR?
We do hands-on competency every year, and also take a written test.
(Source: TJC Prep Guide 2025, HH/HO PT/INR Competency)
Policy 13-003:
New hires - twice within the first year
Annually thereafter
Annual competence will be evaluated and documented using two of the following methods:
(1) Performance of the test on a blind specimen
(2) Periodic observation of routine work by the supervisor or qualified designee
(3) Monitoring of each users quality control performance
(4) Use of a written test specific to the test assessed
RN/PT/OT/ST
Patient lives with another person in the home environment who uses oxygen. Patient does not use oxygen. Is an oxygen assessment necessary?
Yes, oxygen safety assessment is required if oxygen is present in the home, even if the patient is not using the oxygen.
Conduct a home oxygen safety risk assessment that addresses at least the following:
Whether there are smoking materials in the home
Whether there are other fire safety risks in the home, such as the potential for open flames
Whether or not the home has functioning smoke detectors
Then, inform the patient and family/caregiver of the findings of the safety risk assessment and educate the patient and family/caregiver about the causes of fire, precautions that can prevent fire-related injuries, and recommendations to address the specific identified risk.
(Source: Policy 2-041 and User Guide)
RN/LVN/PT/PTA/OT/ST
Unless the physician has ordered specific parameters, what are the Kaiser Permanente parameters for reporting the following to the physician?
BP, HR, O2 sat, Glucometer blood sugar, Temp
SBP less than 95 or over 140
DBP over 90
HR less than 60 or over 100 or newly irregular from SOC baseline
O2 sat less than 95%
Glucometer blood sugar less than 70 or over 250
Oral temp over 100.3
(or Temporal temp over 100.3, Axillary over 99.3, Rectal over 100.3)
(Source: TLH Resources: Clinical Guidance: Clinical Parameters)
RN/LVN
When documenting a wound vac dressing change, what are the components that need to be included in the documentation?
-Verify wound and NPWT on wound avatar
-Wound assessment
-Document any nonadherent layers, # of foam, and type of foam applied and removed from wound
-Suction settings and action
-Document canister exudate type and color, amount, date of last canister change and who changed canister
-Document drape labeled: "SN labeled drape with date, number of foam(s) and nonadherent layers placed in wound, and clinician's initials"
Also document how patient tolerated dressing change, any education provided, etc.
Patient and/or caregiver return demo of ordered alternative dressing must occur in the first visit or two and documented in EHR
(Source: HHH Remote Client Guide: Documenting Wounds; RN Go-To Visit Guide)
All disciplines
May family members act as interpreters for patients? If yes, what is the process?
Family members or friends of the patient will not be used as interpreters unless specifically requested by the individual and after the patient has understood that an offer of an interpreter at no charge has been made (via an independent interpreter). Such an offer and response will be documented in the patient’s record. If the patient chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the patient.
Ensure the family member or friend identified agrees to be present for home visits.
Minors will not be used to interpret, in order to ensure confidentiality of information and accurate communication.
(Source: Policy 1-013)
All disciplines
When are staff required to complete Emergency Preparedness education?
At hire and at least every two years.
(Source: TJC Prep Guide 2025, HH Policy 7-001)
All disciplines
What should you do if you are in an unsafe environment? What should you do with your laptop and other Kaiser-provided supplies?
Your safety comes first. Leave the unsafe environment immediately. Your safety is more important than any supplies or equipment. Please leave your laptop and other items behind if the situation is unsafe, and then alert your supervisor.
RN/MSW/SC
Who are the required members of the IDG? How is the IDG meeting documented?
Members of the IDG:
Physician/NP, Skilled Nursing, MSW, Counselor
Can also include: PT, OT, ST, RD, pharmacist, CHHA, volunteer
(Source: HOS Policy 4-005.2)
The plan of care will be reviewed at least every 15 days and as needed, by the interdisciplinary group.
Input comes from the attending physician, the patient, and the caregiver, based on ongoing comprehensive assessments of the patient and caregiver.
Review of the plan of care will be documented in the medical record. Revision dates will be noted on the plan of care. All involved disciplines should document IDG discussion in their visit notes as well as on the plan of care form.
(Source: HOS Policy 2-044.2)
All disciplines
What are you most proud of in regards to your home care agency?
PI Projects
Care Team Coordination
RN/PT/OT/ST
When must a complete drug regimen review be completed?
How often do your reconcile your patient's medications?
Our policy is that a complete drug regimen must be completed at:
SOC
Recert
ROC
When updates to the comprehensive assessment are made
Any time a change to a medication or unprescribed drug is discovered
(Source: HH/HO Policy 3-002)
Our process is for the medication reconciliation to be done weekly
(Source: TJC FAQ 2025)
RN/LVN
Where do you document the results of the test and which machine you used?
In the EHR there is a point of care test form. We fill out the test results and then in the care plan we document that the test was done, and that the QC check was okay.
(Source: TJC Prep Guide 2025, HH/HO PT/INR Competency)
All disciplines
Whose responsibility is it to monitor oxygen safety compliance?
Every discipline has a responsibility to observe for oxygen safety non-adherence (e.g. smoking with oxygen on, unsafe storage of oxygen, using gas stove with oxygen on, open flames in the home, etc.). Safe storage of oxygen to be temperature controlled
All disciplines: communicate concerns with team
MSW/HHA/RD: Report to Clinical Supervisor and Case Manager
SN and Rehab: Re-assess and Re-educate as appropriate; involve physician/Clinical Supervisor/DME company as appropriate; complete eRRF as appropriate.
(Source: HH Policy 2-041.1, 2-046.1, HO policy 2-075.1, 2-077.1)
RN/PT/OT/ST/MSW/RD
You have received a referral to see a patient for an eval.
After you have completed your evaluation, you determine you need to see the patient for further visits, and the patient/caregiver(s) agree.
What are your next steps?
Communicate with physician, report findings, and obtain physician orders for plan of care.
In addition, communicate/coordinate with rest of HH team regarding your findings and your plan of care.
DOCUMENT all the coordination completed
RN/LVN/PT/OT/ST
How do you respond when the patient's pain is greater than their stated goal? What is the documentation?
Clinicians should initiate pain intervention timely, coordinate care with care team, and document any action taken and patient/caregiver response to treatment (including reassessment of pain level at the end of the visit, and the pain scale that was used) in the patient’s EHR.
(Source: TJC Prep Guide 2025)
RN/LVN/PT/PTA/OT/ST
How often is pain assessed and what is included in the pain assessment?
At EVERY visit: pain when worst AND Current medication/doses in the last 24 hours
Complete full pain assessment for each pain site if patient has had any pain or required an intervention/pain medication in past 24 hours.
Full pain assessment includes:
intensity best/worst (and identify scale used)
location
other pain factors (radiation, quality, onset, frequency, duration, precipitating/aggravating/alleviating factors)
Hospice: Effect on function or quality of life
(Source: HH Policy 2-012, HOS Policy 2-033.1)
RN/PT/OT/ST
Tell me about the Patient Priority (Triage) Codes. What are they used for?
Prioritizes patient contacts based on their priority ranking. Emergency Preparedness Acuity Classification used during an emergency event utilizing the agency’s patient census.
High Risk or Emergent: Patients who require health care intervention within 24 hours. For example: • Receiving PCA, IV; Patients on oxygen
Medium Risk or Urgent: Patients who have had recent exacerbation of diseases process requiring a moderate level of skilled care that should be provided within 2 – 3 days. For example: Those who live alone and for whom interruptions of service would impact their ability to meet basic physiologic and safety needs and no support system available
Low Risk or Stable: Patients who can safely forego care for greater than 3 days without a high probability of harm. For example: • Patients who have a support system of caregiver, family, friend, or neighbor • Caregiver can provide basic needs (e.g., patients in ALF, RCFE, or Senior complex)
(Source: TJC Prep Guide 2025, HH Policy 7-001)
All disciplines
Why is AlertMedia better than calling Dr. Grey?
- AlertMedia connects directly with the correct law enforcement agency based on your location, instead of contacting office staff who then have to reach emergency services
-AlertMedia staff are specifically trained for and experienced in handling emergencies, while office staff handle emergencies infrequently
-Available 24 hours a day
-Works wherever you are, not just while you are in a home (many safety issues occur outside the patient's home)
RN
What are the requirements for a medication list for a patient in a facility?
At each visit, the RN must validate the hospice medication list against the facility medication list with a facility staff member. The RN should also check the available supply of medications and verify that the comfort kit medications are stored separately until they are activated.
All disciplines
What do you do if a surveyor asks you a question and you don't know the answer?
FREAK OUT!!!!!.....NOT!!!!!
Use your Joint Commission Prep Guide as a resource.
Be truthful - if you do not know an answer, say so, and tell the surveyor where or to whom you'd go for the answer. Remember you may use any resources available to you, such as intranet policies, departmental resources, and your supervisor.
If additional assistance is needed, contact your supervisor.
All disciplines
What is your process for identifying and addressing hazardous medications?
A banner in Remote Client indicates when a patient has a hazardous medication, which directs the clinician to review the Medication Detail report. The Medication Detail report identifies hazardous medication and provides information on required precautions. Hazardous medication intervention is initiated in the care plan, including instructions on proper PPE. It includes educating the patient/caregiver on the safe management, storage, handling, and disposal of hazardous medication and patient wastes, and med administration.
(Source: HH/HO Policy Addendum 3-001C)
RN/LVN
Describe how you know the machine is calibrated and working correctly.
Check that the code on the screen is the same as the code on the test strips, no error code, and QC check is on the bottom right of the screen.
(Source: TJC Prep Guide 2025, HH/HO PT/INR Competency)
All disciplines
What is required when documenting coordination with others?
The person's or people's name involved in the communication, the way the communication occurred, and a brief review of what was coordinated.
Names must include, at a minimum, first initial, last name, and job title.
(Source: HO Policy 2-048.1, HH Policy 2-033.1)
RN/LVN/PT/OT/ST/RD/MSW
A staff message has been sent to a physician requesting orders. When can these orders be acted upon?
A physician must approve orders before they are acted upon. This can be via a verbal order with read-back, or waiting for a response to a message.
KP HealthConnect (KPHC) Inbasket Messaging via Hyperspace, Remote Client, or mobile application (i.e., Case Communication or Staff Messaging) is a means for obtaining physician orders and coordinating care between clinicians and physicians. For non-urgent or routine communications, KPHC Inbasket Messaging is used in the same manner as telephone communication. The coordination of care with the physician is documented in the medical record and includes the name of the physician and the reason for the communication. The physician response is also documented in the medical record.
(Source: TJC Prep Guide 2025)
RN/LVN/PT/OT/ST
What is the policy for when wounds are to be measured, ie at what time points and what frequency?
Wounds are to be measured at the following time points:
SOC
Recert
ROC
New wound
Change in wound status
Weekly
(Source: User Guide)
MSW/RD/HHA/SC
If the patient/caregiver identifies new pain or pain above pain goal, what is your responsibility?
Notify patient's case manager directly or RN in the office by the end of the visit
(Source: TJC Prep Guide 2025)
RN/PT/OT/ST
When is the Emergency Preparedness Acuity Classification for each patient updated?
It is intially completed at the time of admission.
It is updated at Recert, Team Meetings, patient status changed & at the time of the emergency event.
(Source: TJC Prep Guide 2025, HH Policy 7-001)
All disciplines
Do we have a Workplace Violence Prevention Program? What is our training?
The WPVP Program is led by the Service Director/designee and developed by the NCAL Regional Home Health Hospice workgroup which is a multidisciplinary team. The team determines what aspects of training are appropriate for individuals based on their roles.
We provide training, education, and resources (at time of hire, annually, and whenever changes occur) regarding the workplace violence prevention program to all leadership, staff, and volunteers.
Training includes:
o Defining workplace violence
o Education on roles and responsibilities
o Situational awareness
o Training in de-escalation
o Response and reporting to emergency incidents.
(Source: TJC Prep Guide 2024)
All disciplines
What is required in the care plan for a patient living in a facility?
Initiate the "Integration of Plan of Care" care plan.
The care plan must identify which provider (hospice or facility) is responsible for performing a specific service or intervention.
RN will utilize the individualized care plan to document coordination of care with the facility, patient, and family, and their response, at each visit.
All disciplines must document their coordination of care with the facility staff (must include the staff member's name)
(Source: TJC Prep Guide)