The new tiered system directs surveyors to focus on quality of care. A detailed list of surveyor probes are provided, outlining questions that may be asked throughout the survey process. Agencies should review the questions outlined for surveyors in order to prepare for the survey process. Preparation for this process will reinforce other patient focused processes. Are you ready? Visit www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf to read more.

CMS stated surveyors would cite more deficiencies under the new process. After one year, it will be interesting to view the stats.

The Key Focus Areas

Patient Rights

Assessments

Plan of Care

Outcomes and Improvement

Infection Control

The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. The surveyor will review the assessment, the medication profile, and physician orders and then evaluate the established plan of care with review of that implementation of the plan of care. Patient and personnel interviews should support the findings of the clinical record.  Prepare personnel for survey interviews so they are familiar with terminology and types of questions they may be asked. Support the interviewees by having them understand that they are the experts in care delivery. They are merely verbalizing the assessment, the care, and the outcomes expected or achieved.

All surveyors are required, by CMS, to utilize these guidelines when evaluating an agency as to compliance with Federal regulation. Remember, the guidelines do not replace regulation and are not allowed to be the basis of any citation, but they provide guidance.  Violations are to be based upon clinical record reviews, interviews with patients, caregivers, and personnel, as well as the agency’s practices in relationship to regulation and agency policies.

“The survey and certification process provides a method for CMS to evaluate HHA compliance with the Conditions of Participation (CoPs), ensuring that patient services provided meet minimum health and safety standards and a basic level of quality. The HHA survey process incorporates an approach that is patient-focused, outcome-oriented and data-driven making it more efficient and effective in assessing, monitoring, and evaluating the quality of care delivered by an HHA…” (Appendix B, p.6).

The surveys are required to have at least one RN on the team.  Surveyors are required to attend the HHA Training Course prior to any survey. They are then required to be in an observational role as part of the training.

Preparing for the Survey

Appoint at least one person, in your agency, to become very familiar with the new survey process. You may want that person to be OASIS certified to readily discuss OASIS conventions. Develop a thorough process-oriented clinical orientation. Be certain all policies and procedures are current and personnel have had the appropriate inservices.

Have a third party or internal coding expert available to answer any questions regarding diagnoses coding conventions, manifestations, and sequencing. A coding audit by an external review agency may give you some peace of mind.

Be certain your clinical lead has reviewed and audited Starts of Care, Resumptions of Care, Recertifications, and Discharges. Be certain the assessments are well documented and the care plans adequately support that proposed Plan of Care.

Be certain the billing (revenue cycle management) audits include the compliance processes that prevent inappropriate billing without a physician order and evidence of all detailed and signed visit notes.

Types of Surveys

The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHAs must undergo a standard survey.

Initial Certification

The initial certification requires compliance with SS Act 1861(0) (4) as well as 2180 regarding licensing requirements. In addition, follow the guidelines of SS2008 “Early Surveys of New Providers and Suppliers”.

The State Agency (SA) surveyor or the National Accrediting Organization (AO) inclusive of Joint Commission, CHAP, or ACHC with deeming authority conducts the initial certification. At the time of that survey, the HHA must

• Be operational and have completed the Medicare Enrollment 855A verified by the assigned MAC.
• Provide nursing and one other therapeutic service (42 CFR 484.14(a).
• Meet the new capitalization requirements and have completed an OASIS test submission.
• Have provided care to a minimum of 10 patients requiring SKILLED care.

Standard Survey

This survey is to be a review of the quality of care and services furnished by the HHA as measured by the medical, nursing, and rehabilitative care indicators. The new changes require this survey to review compliance with regulations most related to high-quality patient care. These highest priority standards (regulations) are called Level 1 standards addressing 9 of the 15 CoPs. The thinking is that if the agency is in compliance with these standards, it is in compliance with all CoPs.

Therefore,  “the surveyor can make a determination  that the HHA is in compliance with all CoPs when, after a review of the Level 1 standards, and after completing the required clinical record reviews, home visits, and interviews with patients and HHA staff, he/she does not discover any findings which would support a deficiency citation.”

Partial Extended Survey

This survey occurs when a standard level survey identifies a non compliant Level 1 standard and/or a deficiency practice may exist at a standard or conditional level not examined at the standard survey.  During this survey, the surveyor reviews at a minimum, the Level 2 standards under the same condition which are related to the non compliant Level 1 standards. See Table 1 Level 1 and Level 2 Standards.

Extended Survey

This survey includes a review of all conditions. It may be conducted at any time at the discretion of CMS and is required to be conducted when any conditional level deficiency is identified. The surveyor is required to review all agency policies, procedures, and practices related to the substandard care (one or more condition –level deficiencies).

Recertification Survey

All HHAs are mandated (SS1891) to have a recertification performed no later than 36 months from a previous recertification survey. These surveys are standard unless a Level 1 citation is leveled.

Now, you know the types of surveys. The following chart lists the standard and partially extended surveys with their related priority standards and G-tags. The more you know about the new process, the better prepared you will be for your next survey.

Level 1 and Level 2 Standards Appendix B

Table 1

Conditions                            Standard Survey                Partial Extended Survey

Level 1                                   Level 2

484.10

Patient Rights                          G107, G109                             G101, G108, G111, G114

484.12

Compliance with                     G121                                        G118

Federal, State, Local

Laws

484.14 Organization,               G123, G133, G143,                 G124, G125, G127, G138,

Services and                             G144                                       G139, G150

Administration

484.18 Acceptance                 G157, G158, G159                      G160, G162, G163

Of Patients, Plan of Care,       G164, G165, G166

Medical Supervision

484.30 Skilled                          G170, G172, G173,                     G169, G179

Nursing Services                     G174, G175, G176,

G177

484.32 Therapy                        G186, G187, G188                      G190, G193

484.36 Home Health Aide      G224, G229                               G212, G215, G225, G226, G230

Services                                                                                     G232

484.48 Clinical Records          G236                                        G239

484.55 Comprehensive          G331, G332, G334,                  G339, G341

Assessment of Patients          G445, G336, G337,

G338, G340

Questions regarding 2011 Survey protocols

Q. We have several questions re the new survey protocols. What are some of the key differences? What does the pre-survey preparation include?

A. The new survey protocols focus on specific standards within identified conditions that are related to quality care. To identify the care delivered and its relationship to the assessment and plan of care designed, besides reviewing the clinical record, the surveyor will also rely on personnel interviews as well as home visits. The survey is data-driven, patient-focused, and outcome-oriented.

The surveyor is expected to collect data and review State file data, prior survey results, OASIS reports, and agency specific characteristics. (S)he will review outcomes, potentially avoidable events of both active and discharged patients, and make visits for higher risk patents. The new protocols provide specific guidance on citing standard and condition-level deficiencies.

Q. Can you explain the survey levels? How is a standard survey extended?

A. A Standard Survey focuses on Level 1 standards (9 of 15 CoPs) which focus on the delivery of high quality patient care using not only clinical records but inclusive of interviews. If the home health agency is in compliance with all Level 1 standards and there are no identified concerns requiring investigation, the survey will be concluded and form CMS 2567 is issued.

Partial Extended Survey begins/expands when expected outcomes are not met for one or more Level 1 Standards. It requires a review of Level 2 standards. It should be expected that related information would be sought for areas of concern such as agency policies and procedures, personnel competency evaluations, and inservice training

Condition-Level Deficiencies can occur with serious findings related to or not related to Level 1 and 2 standards. Immediate patient jeopardy is always cited at the condition level. All conditions are reviewed.  Refer to the State Operations Manual, Appendix B Guidelines.

Questions re CoPs

Q. What are the required leadership positions stated in the CoPs?

A. The Conditions of Participation cite three administrative positions:  a governing body, an administrator, and a supervising physician or RN.  You may title these three positions whatever  your agency prefers, however the positions must exist and the individuals appointed must perform the duties identified in the CoPs. Be certain job descriptions, policies and procedures, and other necessary documentation clearly define that the positions perform all required designated responsibilities.

Do not forget the delegates required. Be certain that agency policy identifies who will function as the administrative delegate. The agency must also be in compliance with state requirements, which frequently are more stringent. Compare both State and Federal requirements so the agency is in compliance.

Perhaps your firm would benefit from a third party quality clinical chart audit. Your Professional Advisory Committee, Board of Directors, and you may well see the merit of an independent view of clinical processes and care. Noting strengths and determining opportunities for improvement before a survey makes sense. Are you spending too much time and money internally for chart reviews? What does happen after those reviews? Do you educate personnel? How do you know if that education was successful?

Clinical chart audits can assist you to remedy issues, provide education and training, and improve efficiencies. Clinical audits can assist to streamline processes, determine areas of risk, and assist to improve the bottom line.  Clinical audits can assist to identify quality customer service and improve patient care.

“Identifying ways that an outcome-based corporate culture fully extends to both internal and external customers is the responsibility of leadership. Developing and using simple tools can aid in the process. Once systems are implemented, maintaining a true commitment to TQM becomes a powerful challenge. But, to the persevering leader, the rewards of quality customer service can go hand in hand with a positive bottom line” (Carmichael, 2005)*

The new survey protocols mandate an outcome–oriented survey process, therefore, know that the surveyor will continue evaluating, per CMS, “the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.” In addition, the new process will emphasize the clinical record of assessment and care, agency personnel interviews, and home visits. The new regulations provide clear guidance for expanding the survey, if needed.

Besides Process and Chart reviews, agencies should routinely use the Surveyor Worksheets to review agency data filed with the state, look at diagnoses and expected outcomes, monitor potentially avoidable event outcomes, and be certain there is adequate documentation for case mix indicators.

An evaluation of Level 1 indicators (see Select Data University April, 2011 article on New Survey Protocols, Survey Protocol Worksheets) includes standards under skilled nursing and therapies. If the agency is in compliance with Level 1 standards and no additional issues or concerns are identified, the survey is completed. If the expected outcomes are not met for one or more Level 1 standards, then the survey expands to become a partially extended survey.

At the very minimum, compliance with Level 2 standards is evaluated if deficiencies were identified with Level 1 standards. This is the partially extended survey. Be aware that surveyors may review additional non Level 1 or 2 standards under the same conditions during the partially extended survey at their discretion. (State Operations Manual, SOM, Appendix B). In an extended survey, all conditions will be reviewed. Appendix B and Survey Protocols provide specific recommendations for: citing condition-level deficiencies, extending the survey, and related conditions for further survey.

Now, more than ever, a thorough assessment must drive discipline specific care plans that drive the overall POC with every visit skilled and enhancing the process toward expected outcomes. Clinical record reviews, clinical interviews, and home visits drive the survey process. Documentation is essential. Good documentation starts with a thorough assessment. That assessment should be specific. Does your assessment tool set the stage for success? Is it detailed enough to gather data to allow the highest level of coding specificity? Does it cue the clinician with requests for detail to support a case mix diagnosis that may be assigned?

It is simple in the guidelines; a good POC starts with a solid clinically integrated OASIS assessment. That assessment drives the discipline specific care plan and those plans contribute to the overall POC. That POC has diagnoses present that require substantiation in the clinical record and the expertise of master coders. That very record supports the diagnoses sequences chosen. The visits can stand alone as to skill but reflect that they are a part of an individualized skilled plan of care.

Documentation takes time and thought. Clinicians are busy and require assistance and support. Consider a third party coding entity. Also consider an OASIS data collection service that was created by clinicians.  The system should be reflective of what you expect and of what your clinicians need.

The new survey protocols are data driven. Agency leaders need real data daily, weekly, monthly to monitor clinical performance and patient care outcomes.

The Surveyors have the data when they arrive. Do you?

*Carmichael, S (2005). Total quality management and outcomes based quality improvement: revisiting the basics. In Home Health Care Management and Practice (17)(2),119-124

1. All learning is physiological
2. The brain/mind is social
3. The search for meaning is innate
4. The search for meaning occurs through patterning
5. Emotions are critical to patterning
6. The brain/mind processes parts and wholes simultaneously
7. Learning involves both focused attention and peripheral perception
8. Learning always involves conscious and unconscious processes
9. There are at least two approaches to memory

10.  Learning is developmental

11.  Complex learning is enhanced by challenge and inhibited by threat associated with helplessness

12.  Each brain is uniquely organized

(Caine, Caine, McClintic, and Klimek, 2009 and Caine and Caine, 1994)

The principles assist us, as clinicians, leaders, managers, to understand that there are several different processes involved. Yet, we all tend to print up some teaching materials and have the nurses leave them with the patient “for reinforcement”. Many people believe, “If I told you, you have had education”.

The best selling education books, Tellin’ ain’t Trainin’ (Stolovitch, 2011) and Sit and Get Won’t Grow Dendrites (Tate, 2004) help us to better understand Brain-Compatible strategies. Some patients may learn well with the written word, while others are spatial and auditory learners.

Future Select Data articles will explore the constructs further but here is one sample activity.

If a patient treatment has changed or is being compared or contrasted, consider using a Venn Diagram. Draw two circles that have an overlapping center like below:

Information that is overlapping in the center is that information that is alike. The information outside that space identifies differences.

A spider chart with the new treatment or new topic in the center of a circle should be drawn. Then draw “spider-like” lines coming out of the circles. These can be goals to be achieved. As the patient articulates each goal they desire to achieve, linking it to the treatment or med in the center of the chart dramatically diagrams the importance of that treatment or medication.

A pie chart can be used to classify the careplan components. Breakdowns can make the plan seem more manageable. Each component or “piece” of the pie can appear to be managed at a setting, much like a tasty lemon pie.

We will look at this topic with more depth in the future. There is a PowerPoint Presentation on the topic of Learning and Brain Compatibility that is based on the Twelve Adult Learning Principles. This presentation was presented at two state association conferences and it could be shared with clinicians.

Having trouble downloading Learning and Brain Compatibility PowerPoint?

right click on the link > Then choose “Save Target As” > “Save”

]]> http://www.selectdata.com/adult-learning-principles-influencing-patient-outcomes-through-education/feed 0 http://www.selectdata.com/educational-video-new-survey-protocols http://www.selectdata.com/educational-video-new-survey-protocols#comments Wed, 20 Apr 2011 14:39:50 +0000 Brian http://www.selectdata.com/?p=1493 CMS New Survey Protocols Clinical Compliance

Surveyors will, more in depthly, prepare for surveys, using OASIS data. They will review any complaints, previous survey data, and reports generated from the OASIS data. Available OASIS reports can be generated for specific time periods, as requested, from the OASIS Coordinator’s office. These reports include case-mix, potentially avoidable events, risk adjusted outcomes based quality improvement (OBQI) or process measure reports.

More Videos

To view related videos click here.

According to the official CAHPs government information site, the survey is a “public-private initiative to develop standardized surveys of patients’ experiences with ambulatory and facility-level care.” The survey is intended to:

• Determine the quality of care to the individual;
• Document performance; and
• Advance the overall quality of care.

This particular survey is a general collection of information dealing with Home Health Care providers and the relationship to their patients. The survey’s intentions are to relay feedback to the service provider. An assessment of the results will be made and an evaluation of each Agency will occur.

Who will be taking part in the survey specifically?

If a patient’s care is paid for by Medicare and Medicaid, then they are eligible to be included in the survey. However, a patient has the right to deny participation.  Patients excluded from taking the survey are those under the age of 18, those receiving hospice care, and maternity clients.

The survey has been identified as a voluntary survey process; however, the final rule makes it clear that non-participating agencies will be subject to a two-percentage point reduction in the market basket update in 2012.

The Survey Itself: The Patient’s Opportunity to Voice Their Opinion

The survey contains an arrangement of questions related to safety, medications, pain management as well as communication and interpersonal interactions. The patient will also be rating the agency overall and the likelihood of recommending the agency to others.

-To begin, the survey asks a series of yes or no questions about Your Home Health Care provider. These questions will aide in revealing the general relationship that each Home Health Agency has with their patients.

-The next set of questions will determine the experiences sustained by the patients with their agencies specifically within the last 2 months.

-Following this segment is a series of questions dealing specifically with the Home Health Agency offices and the patient’s evaluation of them.

-The survey concludes with a few personal questions asked of the patient. Some of the categories include education, ethnic background, current health, and living status.

Although the standard survey contains 34 questions, Agencies/Vendors may add additional questions, which do not need to be approved by CMS (Centers for Medicare & Medicaid Services). However, additional questions will not be publically reported by CMS, only the questions originally asked in the survey. When an agency receives the survey, questions may be added, but no questions are approved for removal. All of the original questions must stay in place. The target number of surveys that an agency must administer per year is around 300.

The survey is offered in various languages to suit diverse clients.  The languages included are English, Spanish, Chinese, Russian, and Vietnamese. Once the survey is completed, 3 options as to how the data will be collected is available to the client:

1. By Mail: The client must send in the completed survey and cover letter within 3 weeks of the month end. If the survey is not mailed in, a second survey will be mailed to the client.
2. Telephone: The client can choose to respond to the service by telephone only.
3. Both: This option includes a mailed survey and a follow up phone call if there is no response to the mailed survey.

Financially speaking, an agency is looking at a cost of about $3300 to $4500 annually for 300 surveys, with the price of a mail survey being around $11.10 to the telephone survey being $15.25.

Timing and Vendors

The regulations set forth by the department of Health and Human Services for the HHCAHPS become effective January 1, 2010. The survey must be implemented by the third quarter of 2010 (July, August, September). Any data that is submitted to CMS within the third quarter will not be publically reported. The public reports will reflect one year’s worth of data.

As for administering the survey, each Home Health Agency must use an approved vendor to distribute amongst their clients. For a list of a few approved vendors, see the CMS website.

The Ghost of a Good Thing

Although the CAHPs survey may be new to Home Health, it has already been initiated into the world of Health Care. For example, between October 2006 and June 2007, the HCAHPS (Hospital CAHPS) survey was discharged and completed by the patients of hospitals. The survey evaluated patient satisfaction and collected invaluable information that allowed medical providers to gain insight for improvement and notified them of already existing flaws. The findings were posted on the Hospital Compare website where a downloadable file of the data is also available. As for the Home Health CAHPS data, the concluded results will be available to the public in early 2010 on the Home Health Compare website at http://www.medicare.gov.

Latest Update

CMS has announced that of the 10,500 certified home health agencies, only about 20% of the agencies have chosen a CAHPs vendor. Exceptions (having less than 60 patients) have been applied for by 9% of agencies. That means that nearly 70% of Medicare certified agencies have not completed the required steps found at www.homehealthcahps.org.   Data reporting requirements of HH CAHPs necessary to receive full market basket update in 2012 can be found in the Federal Register notice entitled HH PPS Update 2011 at http://edocket.access.gpo.gov/2010/pdf/2010-17753.pdf.