CMS has developed a new survey process for Home Health Agencies that will be effective May 1, 2011. It is data driven, patient outcome-oriented, but according to CMS, is less structured yet very process oriented.
For more detailed information, visit http://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf to read the advanced copy.
Under revised survey protocols, agencies will be evaluated on a set of 34 standards, known as Level 1 standards. If the surveyor finds a deficiency on any one of the new highest priority standards, a partial extended survey will be conducted.
During that survey, the agency will be evaluated on 27 Level 2 standards. Both sets of standards fall under the nine conditions of participation. Surveyors must conduct extended surveys of all CoPs when any of the more serious condition level deficiencies are cited. Part 1 of this series outlined each CoP and where the G Tag fell; Level 1 or Level 2.
Many agency leaders are stating that it seems the new survey process has more detailed guidance to reduce surveyor inconsistency.
The survey tasks have been clearly delineated by CMS:
- Task 1- Pre-Survey Preparation
- Task 2- Entrance Interview
- Task 3- Information Gathering
- Task 4- Information Analysis
- Task 5- Exit Conference
- Task 6-Formation of the Statement of Deficiencies
Pre-Survey Preparation
Surveyors will prepare for surveys, more indepthly, using OASIS data, previous survey findings, and complaints filed. 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.
OBQM Potentially Avoidable Events Report
Know that before coming to the home health agency, the surveyor will have reviewed the most recent quarter of OASIS data to identify patients with emergent care as a result of a fall at home or emergent care for wound infection or deteriorating wound status. This is a Tier 1 event. There are six Tier 2 Potentially Avoidable Events for consideration. To reach the threshold there must be patients who experienced the event and/or the agency to be surveyed must have a current incidence rate equal to or greater than twice the reference rate (Appendix B p.12)
OBQI Outcome Report
Surveyors will also review the agency’s Risk-adjusted Outcomes Report prior to survey. CMS instructs surveyors : “During the onsite survey, select patient records and home visits that focus on the outcomes identified on the OBQI report meeting the individual investigation thresholds” (Appendix B. p12). If none of the ten listed outcomes trigger the selection criteria, another outcome should be selected from the OBQI report (that meets the selection criteria).
Patient/Agency Characteristics Report
As part of the pre survey process, the surveyor will look at this report for the same timeframe as the OBQI Outcome Report and focus on acute conditions and home care diagnoses that are statistically significant or are equal to or greater than 15% points higher than the reference rate. The surveyor is to choose up to three diagnoses or conditions that meet the criteria and look at corresponding patient records.
Error Summary Report by HHA
Surveyors will be looking for several inconsistencies and errors, such as inconsistent M0090 date and incorrect record sequence. The latter error could trigger further record reviews if the HHA’s percent of assessments with this error in or above 10%.
What Can an Agency Do on an Ongoing Basis?
Routinely, agencies should be reviewing the online OASIS reports and identifying areas for improvement. They should show interventions planned and implementation of the plan. The agency should also reflect follow up to implementation. This practice establishes a commitment to Quality Improvement and seeking proactive interventions for areas such as recurring hospital admissions.
Part 3: Entrance Interview
CMS remains detailed as to activities that are to be included in the entrance interview. This interview sets the tone for the survey process identifying expectations. We will explore those in the next article.