Are you caught in a Regulatory Nightmare? How to be proactive with a methodology to avoid “Survey Panic”.

One year after Medicare’s new Home Health Conditions of Participation (CoP) have gone into effect in the home health industry, many agencies have struggled with understanding and implementing the new regulations. We have seen the “Deer in the Headlight” phenomena in some agencies, leaving the agency out of compliance, and the management extremely stressed about what to do to comply.  Unfortunately, we have been engaged by many agencies after they have had an unsuccessful survey under the new CoPs and have been cited with numerous standard level deficiencies, condition level deficiencies and even immediate jeopardy.

Although the new CoPs are numerous, complex and at times head scratching, having a plan and working towards the goal of continued survey readiness is very possible.  In addition to agencies being cited on new conditions and standards, there have been many deficiencies cited in areas that have not changed at all.  This indicates that an agency must continue to focus on all of the CoPs and not solely on the new ones. There are some standards that are easy to comply with, thus agencies should ensure compliance with those (example: content of the patient bill of rights, Administrator and the clinical manager contact information and contact information for federally funded organizations must be given to the patient).

What further steps can be taken to avoid unsuccessful surveys?

To start with, the Administrator must ensure that all management in the agency have read and clearly understand the CoPs, utilizing the State Operations Manual which includes the Interpretive Guidelines (IG).  The IGs are so important because they offer clarification and are what surveyors utilize.  This sounds so basic and yet we have seen many times in which these have not been read or fully understood.

Do not neglect the state regulations and if accredited, those standards. Remember to always follow the most stringent regulations. When the management fully understands the regs, this is the time to prioritize areas in which your agency is noncompliant – often just reading them, you realize that you are noncompliant.

It is so important for each of the HHA staff to also understand the CoPs / state regs/ AO standards as these are the rules that they must follow.  Management can teach specific standards to all staff, rather than having them read the entire regulations at once. Ofttimes, once I have shown and explained a standard to a field clinician, then they comply, as now they know the reason for having to perform some task or documentation.

This concept of involving all staff is what 5 Star’s philosophy is for agencies to understand the regulations and QAPI, infection control, patient rights, clinical standards and more. Involving all staff empowers and educates them, ensuring better compliance and engagement in the agency.

Agency Assessment / Mock Survey

It is so important to do a complete assessment, i.e., mock survey of your agency in the same manner that a surveyor will perform one.  Covering all the same functions as for an actual survey is the only way that an Administrator can really know where the agency stands. I recommend performing these once a year so that the agency can work towards continued survey readiness.

This mock survey can be done by a qualified person in your agency, or if you are a multi-site agency, it is good to assess each other’s locations for objectivity. Note that I said qualified, as the person must know how to review clinical records, what to look for on home visits, what constitutes a compliant QAPI program etc. Therefore, some training may be needed prior to having an in-house mock survey. Of course, you can utilize outside companies who provide mock surveys, however, ensure they too are qualified.

During the mock survey, you will look at many areas, including clinical records, home visits, HR files, education/competency, Emergency preparedness, QAPI, infection surveillance, Governing body minutes, staff interviews, policies, and more.

The results of the mock survey will indicate vulnerabilities of your agency. Some of these can be corrected easily by revising a policy whereas others may need a task force that focuses on a specific project, such as medication management.  As you review this information, you can concurrently develop your QAPI program.  Easy fixes would not typically be a quality indicator.  But many areas noted in the clinical records, home visits etc. would be quality indicators and/or performance improvement projects (PIP)- such as the example of medication management (this is a complex, high risk area involving numerous people, documentation and coordination which can require a PIP).

QAPI Program

By developing a formal QAPI program post mock survey, with further monitoring of the data, trending/analyzing and implementing action plans, you have a compliant QAPI program. The agency’s non-compliant areas will improve with the QAPI monitoring, particularly when all staff are involved. At the same time, you will be improving your patient and agency outcomes, by including data driven outcomes from CASPER outcome reports.

When you have your quarterly data that indicates deficient areas, ensure that your action plan is very specific. Typical components of an action plan will include education, policy and/or process change and quality monitoring.

Example Findings/ Action Plan:


In 6 of 8 wound patients, clinical records indicated physician orders for wound care were not followed. (State for each chart specifically what was not followed)

  • Patient 6 – Wound care was not followed to physician orders Jan 10 – Jan 12 (state order and care)

Action Plan:

Quality Indicator:   The DPS to review 100% of wound care patient records a quarter to focus on following physician orders with a goal of 90% compliance.   After goal is achieved, review will decrease to 20% records a quarter.

  • Audit Tool – Have the audit tool designed for this particular deficiency (Example: Wound Care)
  • Education – In-service to ALL skilled nursing will be done. (Example: 2/15 by DPS – following physician orders for wound care; 3/1 by Wound Care Consultant regarding wound care types)
  • Home Visits with wound certified nurse and all nurses on wound patient by end of May.

Interdisciplinary Team Management

Another key portion to ensure your clinical aspects of the agency are in compliance is to have interdisciplinary care teams working together on patients from admission through discharge. This team must ‘talk’ regularly and ‘report’ to each other whenever there are any changes to the patient and/or if the current POC is not meeting patient goals, such as ineffective pain management. Compliance can be achieved with follow through of patient changes through physician notification, as an example, if the entire patient team is on the same page. All of the communication can be documented in coordination of care sections in the EMR, so that each clinician and aide can easily view ‘reports’ given to each other with actions taken.

Not only will this assist your agency with compliance but will improve the agency standing for VBP and Star ratings.  Often, your patient’s CAHP scores will improve as your clinical team is goal oriented towards improving the patient’s outcomes.

As you can see, the stated proactive methodology to ensure compliance with the CoPs can make your agency a high-quality agency that will ensure your agency’s viability for the future.

Southern Web SupportAre you caught in a Regulatory Nightmare? How to be proactive with a methodology to avoid “Survey Panic”.
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