Completing the Survey Process

Your Plan of Correction (POC) may be written and submitted, but this does not necessarily mean the survey process has been finalized for your home health agency (HHA). Yes, your HHA has completed many of the critical steps, but you may ask what comes next? In this blog we will explore what to expect after you submit your Plan of Correction.

What to Expect Next

After your HHA completes and submits its POC, the State Agency (SA) or Accrediting Organization (AO) will inform you if your Plan of Correction has been accepted or if it needs to be revised. If your POC needs to be revised, the report will cover the areas of concern that need to be addressed, why the POC was not accepted with its revisions, evidence necessary for compliance and the allotted time frame in which the revised POC must be submitted to the SA or AO. The evidence to support correction of each deficiency and to demonstrate compliance is typically due 90 days from the date of the survey. However, in addition to addressing these concerns, sometimes a return on-site follow-up visit is required.

Addressing Condition-Level Deficiencies

As we addressed in our blog on deficiencies, a Condition-Level Deficiency is a more serious type of deficiency than a Standard-Level Deficiency. This level of deficiency is issued if a surveyor determines that your HHA is not in compliance with a Condition of Participation (CoP), such as not having a formal agency wide QAPI program. Also, a Condition-Level Deficiency may be cited if your HHA receives two – three (or more) Standard-Level Deficiencies.

When a Condition-Level Deficiency is cited, the State Agency or Accrediting Organization will notify Medicare that the HHA has a Condition-Level Deficiency. The SA or AO typically will return for a follow up on-site visit in approximately 30-60 days from the last day of the HHA’s survey. The purpose of this visit is twofold: evaluation of agency deficiency corrections and compliance. If it is determined that the HHA is still noncompliant and cannot show evidence of performance improvement, then Medicare Certification can be terminated. Also, it can be terminated if upon a return visit (usually in another 30 to 60 days) improvement is demonstrated, but still the HHA is not within total compliance. In addition, a HHA will not be able to competency aides for two years for any condition received, not just Aide Services.

The Plan of Correction for the Condition-Level Deficiency includes the same elements that require a specific action plan to correct and prevent future noncompliance. The difference is that the Condition-Level Deficiency typically must be abated within 10 calendar days of the survey findings.

It is key to remember that the Plan of Correction is an important legal HHA document that the Administration should understand. It is more than a process that must be completed and then filed away. The Plan of Correction should be used in the QAPI plan for ongoing monitoring of compliance and can be used in litigation if applicable.

Ensure Compliance is no Longer an Issue

Since opening our doors in 2003, 5 Star Consultants have helped ensure hundreds of home health agencies are in compliance. Whether they have received Standard-Level or Condition-Level Deficiencies, our team of former or current AO surveyors has worked side-by-side with a HHA’s staff to help guarantee any deficiencies have been corrected and Medicare Certification will not be terminated. For further information about our services and how we can possibly assist your home health agency, please contact us at [email protected] or 866-428-4040.

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