Your Mock Survey is Finished, Now Let’s Talk about Next Steps

Your home healthcare agency recently conducted a mock survey. Unfortunately, it did not go exactly as planned, with many deficiencies being uncovered, including vulnerabilities to condition level deficiencies.  Keep in mind that these issues were found by you, not the surveyor.  This means before the state or another accrediting body comes knocking on your agency’s door some work needs to be done first in order to be ready.

Action Plan

Your mock survey uncovered your agency’s deficiencies so the next step in the readiness process should be the development of an action plan.  An action plan should have the following specific categories related to the deficiencies cited:

  • Priority
  • Findings with specific issues
  • Action items
  • Responsible party
  • Projected completion date

The prioritization of deficiencies is key as it is easy to lose focus on the major vulnerabilities that could lead to condition level deficiencies.

Spend the most time on your biggest problems!

Specific findings will be cited in the action plan.  An example would be following physician orders:  in 3 out of 10 clinical records reviewed, there was no documentation regarding following physician orders.

#1-pt MR# – There was no blood glucose level documented on the 3-21 skilled nursing visit as per orders.
#5-pt MR# – There were no weights documented on skilled nursing visits as per orders.
#7-pt MR# -There was no documentation regarding the site to which the therapist applied the ultrasound treatment as per orders.

Action items include all the steps you will take to ensure that this will not be a deficient area in the future.  Key areas of action typically include staff education, monitoring of the activity via a QAPI indicator, and /or process / policy changes.

An example would be educating field clinicians regarding compliant documentation of physician orders on every visit note; a QAPI indicator to address following physician orders: Ex: 50 percent of clinical records will be reviewed quarterly by the QAPI RN or designee for following physician orders with a 95 percent threshold goal.  The audit tool would then address the areas of physician orders that were found to be deficient, such as documenting blood glucose results, weights, specific orders for therapy treatment, and more.

The Responsible Party is key so the Administrator is able to hold both the party accountable as well as to keep focus on each issue being addressed.  That responsible party must ensure the action items are completed by the specified date.  Unlike a corrective plan that needs to be completed for the actual regulatory surveys, this is a projected completion date, as each finding may involve much more complex areas than others.

For example, an issue that involves patient safety must be addressed immediately to abate the deficiency, but may have many prongs to ensure that the situation never happens again.  This may involve a task force to perform a root cause analysis of the issue.  The task force may determine that communication and coordination of care, understanding agency policy, compliant documentation, and more major areas that will need to be addressed.  This could lead to several process and policy changes, ongoing staff education, adding indicators to the QAPI program and more.

On the opposite end of the continuum, you may have a finding from the mock survey that could be addressed quickly and rather easily, such as the days and hours of operation were not posted on the agency door.

Keep Working Your Action Plan

Often after a mock survey is completed and numerous deficiencies are cited, we find the agency management to be very concerned with the outcome and wants to resolve all deficiencies post haste.  Therefore, initially they ensure that the action plan is worked   diligently.  However, as the busy day-to-day operations filled with problems and diversions occur, as will happen, the action plan follow up gets moved to the bottom of the pile.  Don’t let yourself fall into that trap!

By working the action plan until all findings are addressed, and then following up with monitoring in the QAPI program, you will be in a continued survey readiness state, which is so critical in today’s world of home health!

Remember, that to be a participant in Medicare Certified Home Health or Hospice, you must be in compliance with the Conditions of Participation (CoPs).  And if you are found to not be in substantial compliance, you are vulnerable to condition level deficiencies and even immediate jeopardy.  For home health, sanctions can be enforced for not only immediate jeopardy, but for condition level deficiencies.  These can be non-monetary – such as management of the agency and/or monetary – with daily penalties of $500 -$10,000 until the corrective action plan is completed and approved as compliant.  Agencies often cannot survive sanctions!

So, the moral to the story is to find out what your agency deficiencies are before a regulatory survey body does and fix them!  Most importantly, ensure that those deficiencies do not arise again in the future, so develop a QAPI plan that works for you and is not just busy work!

Invest in staff with such activities as being members of task force committees, part of the QAPI team to review aspects of a clinical record, assisting with process development and education.  You will be rewarded time and again when you have an engaged, informed staff.

Agencies in continued survey readiness can enjoy increased patient outcomes, increased referrals, increased client satisfaction, lower staff turnover, and increased employee morale, and of course better survey results!

In Need of Assistance?

Our experts at 5 Star Consultants can work with your team to implement an action plan that will help you to stay in compliance!  We offer years of experience speaking about and consulting on this key topic.  If you would like us to put our experience to work for you and your staff, please contact us at (866) 428-4040 or [email protected].

Southern Web SupportYour Mock Survey is Finished, Now Let’s Talk about Next Steps
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