CMS states that survey protocols promote consistency in the survey process. The goal is to assure that a “facility’s compliance with regulation is reviewed in a thorough, efficient, and consistent manner…” The protocols also state:
“Surveyors gather critical information by focusing on home visits, interviews, and clinical record reviews.”During the standard survey, activities are to focus on Level 1 standards unless issues are found.
The entrance interview (Surveyor Task 2) sets the tone for the entire survey and CMS views this as a critical first stage of the onsite visit. Upon arrival, expect the surveyor to introduce herself, display identification, and to identify to the administrator, director, or supervisor the purpose of the survey and the number of expected days to conclude the process. On the survey team, CMS states, there should be a RN with home health experience.
Expect the surveyor (team) to:
- Ask who will be attending the entrance survey.
- Explain the survey process and the anticipated days required for completion.
- Request a current organizational chart and discuss lines of authority, as well as delegation of responsibility and services provided (directly and by arrangement).
- Request explanation of relationship to any other corporate structure as well as identifying any branches.
- Ask for the present census number, scheduled visits for the week, and the number of unduplicated patients admitted receiving skilled services for a recent 12 month period.
- Ask for a list of all employees as well as all personnel under arrangement.
- Ask for a list of all key personnel knowledgeable about:
- Home health aides
- Inservice trainings offered as well as attendance sheets
- Clinical supervision processes
- Key resource to respond to surveyor questions
- Ask for the process to have unrestricted access to clinical records.
- Request access to all active patients paid by Medicare, Medicaid, or private pay. Identify the SOC date, primary diagnosis, and services provided. This list will assist to derive the home visit list.
- Request discharged/closed records for review from agency’s Potentially Avoidable Event Patient Listing report.
- Identify personnel to interview.
In order to gather the information (Surveyor Task 3) needed for survey compliance with Level 1 standards, the surveyor will be asking questions, completing interviews, and preparing for home visits. Areas that may be explored include:
- Complaint investigation processes
- Review of admission packets as to complaint process explanation and patient rights.
- Ask how agency ensures all personnel and contractors adhere to agency policies and procedures.
- Ask about any staffing challenges, monitoring of clinical competency, supervision of LPN/LVNs.
- Ask how agency staffs therapy and how qualified therapists supervise assistants.
- Ask if home health aides are employees or provided through arrangement.
- Ask how home health aide supervisory visits are tracked.
- Ask if physician electronic signatures are accepted and the related policy.
- Ask how clinical records are maintained. If there are electronic records, ask for the tutorial re accessing records.
- Ask timeframe for documentation to be turned in by clinicians and monitoring process.
- Ask re HHA policy for record corrections and for conducting assessments (can therapists complete these per agency policy?).
- Ask about any issues identified on pre-survey pulled reports.
- Establish a time to discuss indepthly the drug regimen patient review when therapy completes the assessment; how does the agency deal with drug order differences (what patient is ordered vs what is found in the home).
- Ask when and how it is determined that an updated comprehensive assessment is needed.
- Discuss tracking systems, supervisory visits, and due dates for updating comprehensive assessments.
“Non-clinical record materials are not reviewed unless problems are identified through HHA staff interviews, patient caregiver interviews, home visits, and clinical records. If problems are found with Level 1 standards, surveyors move to a partial extended survey and evaluate Level 2 standards as necessary. If concerns arise during interview, record reviews or home visits, it may be necessary to include a review of additional material as needed, such as personnel records, contracts, policies and procedures, clinical procedural references, documentation of home health aide training and/ or competency evaluation, documentation of complaint investigation and resolution, CLIA waiver, and/or other materials.”
Interviewing Clinical Manager
The surveyor will be requesting information re assurance of adherence to agency policies, physicians’ orders, patient/client confidentiality, error identification, drug regimen review, and timeliness of assessment completion.
Additionally, expect to dialogue re location (in the clinical record) of documentation of supervisory visits, case conferences, phone calls, medications, and wound care. Expect to be asked, “How do you handle prescriptions from physicians other than the physician responsible for the patient’s home health care?”
The Clinical Manager should be ready to identify clinical and other additional resources available. They should be able to address who is responsible for aide patient care instruction and where it is documented. Is there a copy in the home?
Interviewing Clinicians and Case Managers
Clinicians should expect to answer questions re the process for involving patients and their care givers in their care. They should be able to discuss the communication process involving patient condition as well as discharge planning. “How is the same information shared among the appropriate care providers (including physicians and aides)?” (Appendix B, p.17)
Does the clinician know how to obtain assistance re a difficult clinical issue? How does the clinician ensure the safety and confidentiality of patient records when information is transported for use in the patient’s home? What is the process for making a correction in a clinical record? How do you handle prescriptions from physicians other than the physician responsible for the patient’s home health care?
Notice that similar/same questions are being asked of various personnel levels. Notice that patient care, medications, and physician involvement in patient care is emphasized.