Home healthcare is a highly regulated industry and unfortunately, regulations are constantly changing. Ensuring your agency is in compliance before the next auditor shows up unexpectedly at your doorstep entails preparation and practice. A mock survey is an invaluable tool that should be used by all home healthcare agencies.
The Purpose of a Mock Survey
A mock survey is an opportunity for an agency to take a fresh look at systems, procedures and processes of care and identify potential areas that may be at risk. These at-risk areas can turn into much bigger issues, which may be accompanied by legal ramifications. Next, a mock survey can reveal how staff will handle stressful circumstances. Finally, during a mock survey you may discover that doing a certain procedure as it “always has been done” may no longer be adequate.
Preparing for a Mock Survey
There are a few different steps you can take to prepare for your mock survey. First, review your previous regulatory surveys. These include ones conducted by the state, CMS (Centers for Medicare and Medicaid) or other accrediting bodies such as the Accreditation Commission for Health Care (ACHC), the Community Health Accreditation Program (CHAP) and The Joint Commission (TJC). Close attention should be paid to the results of your previous surveys. If any deficiencies did occur, be sure your plan of correction is still working because you want to avoid repeat deficiencies. Also, it is key to review your QI (quality improvement) program. This can entail reviewing the OBQI (Outcome Based Quality Improvement) report, potentially avoidable events, and process measures from the CASPER system.
Mock Survey Documentation
To properly conduct a mock survey many documents and procedures need to be followed. In the beginning of the survey lists are critical. These lists include one containing unduplicated patients for the prior 12-month period. Active and discharged patient lists are key too. These lists need to be easily accessible and up-to-date with primary diagnoses and disciplines, if possible. Next, you should have active/terminated employee lists readily available. These should include their discipline, status and date of hire. Finally, schedules of home visits with locations should be part of the process. These schedules should include all disciplines and contract personnel.
There are many other documents that are necessary for the mock survey. First, review of administrative policy and procedure manuals and the clinical procedure manual should be done. Surveyors often ask for specific policies and clinical procedures when they observe home visit techniques and procedures that are not standard and in compliance; therefore, you should do the same during your mock survey.
Your previous state survey / accreditation reports, along with any deficiencies and action plans are necessary to review. You want to ensure these deficiencies will not be repeated and your action plans are being enforced. If they are not compliant, they could lead to condition level deficiencies and possibly sanctions, so this is very important.
QAPI is a critical area to review in-depth. Review the previous year’s QAPI plan to ensure it is an agency wide comprehensive program. If you are accredited, this is already in your standards. However, with new CoPS coming out any day now, it is important for all agencies to have this in place or in process. Look for the indicators, the criteria for each indicator, the results of monitoring, trends, analysis, and most importantly action plans.
Be sure that the QAPI program ties in with what you find in clinical records and home visits. For example, many times I have seen QI clinical record reviews with a 90%, while my result of reviewing the clinical records are in fact 70%. This could show that the auditors do not understand how to review the clinical record and/or that the audit tool needs to be more comprehensive.
Home visits are a very important component of mock surveys. To adequately prepare for them, approximately the same number of home visits should be conducted as a surveyor would perform. These home visits should cover matters relating to a variety of matters such as wounds, multi-disciplinary, therapy only, IV, and aide services. All clinical records should be reviewed prior to any visit. Also before the visit occurs, the clinician’s car set up and supplies should be evaluated.
As part of the home visits, multiple interviews need to be completed. Not only the clinician, but the patient and/or caregiver should be included in the interview process. Questions must be asked like a surveyor. They can entail topics such as any complaints, accessibility after hours, clinicians communicating their arrival times, infection control, etc.
During a home visit locate and review the Home Folder, which should include a signed copy of consent, a medicine list, etc. Check to see if physician’s orders were followed. Finally, during the visit – just observe. Only intervene if there is a safety issue, as a surveyor would do.
Clinical Record Reviews
Of course, a mock survey should include a review of clinical records. As part of the clinical records review process, it is key to go over a variety of records – wounds, various diagnoses, post operation, multi-disciplinary as well as therapy only. The most recent full certification period to the present should be examined. Ensure the audit tool is appropriate to what the surveyors use for reviewing.
Commonly seen deficiencies, which should always be on your radar, include:
- No coordination of care and/or communication between the disciplines and/or physicians.
- Not following physician’s orders regarding visits and treatments. Proper wound care is a common issue.
- Not having physician’s orders concerning medications and interventions.
- Aides not properly following aide care plans.
- Supervisory visits that have not been completed, including Ai, LPN, PTA and COTA.
As part of the mock survey, conduct a walk-through of the agency to review fire safety, infection control issues, bio hazardous materials, medicines and supplies that require refrigeration and the safe keeping of any confidentiality documents.
Human resources files should be reviewed as well. All disciplines and clinical management files should be included. Choose a few of each discipline. Be sure to review education and competency as well if these are separate from the human resources files. And the separate health files need to be reviewed too. Look at contractor files, whether a company or independent contractor. Ensure orientation, licenses, and competency are compliant.
How to Handle Deficiencies
For each “no” a deficiency must be described. These deficiencies can be cited from state, CoPS and accrediting organizations in order to help all understand the “why”. Once staff understand the “why” then they should take action. It makes it much easier for them to comply. Here is an example – three of eight clinical records reviewed did not follow physician orders. Then list the three specific clinical records with patient initials and the issue(s) found. Your action plan may include: QAPI coordinator will review 25% of clinical records quarterly to ascertain that physician orders are being followed, with a 90% threshold. Then have an appropriate audit tool. Another action item should always be to educate your staff on specific findings and how to increase compliance. Working your action plan is critical to continued survey readiness.
Turning to an Outside Firm
Conducting a mock survey is a critical and time-consuming process. It can be conducted using internal resources. However, if you are not properly prepared the surveyor will not only not find new deficiencies, but possibly repeat ones, which can turn into a much larger issue, such as conditions, immediate jeopardy and sanctions. It is so critical that staff performing the mock survey are knowledgeable of the regulations and know what to look for.
Our team members at 5 Star Consultants have years of experience conducting mock surveys. We can help to prepare your agency for the next survey and alleviate your concerns. If you would like us to put our mock survey experience to work for you, please contact us at (866) 428-4040 or [email protected]