The CMS new survey protocols have been in effect for over six months. The revised Home Health Agency Survey Protocols and New State Operations Manual are available online. The new survey process is data-driven and patient outcome-oriented with a focus on patient visits and personnel interviews. Though it appears less structured, it is very process-driven.
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
Plan of Care
Outcomes and Improvement
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.
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.
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.
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).
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
Conditions Standard Survey Partial Extended Survey
Level 1 Level 2
Patient Rights G107, G109 G101, G108, G111, G114
Compliance with G121 G118
Federal, State, Local
484.14 Organization, G123, G133, G143, G124, G125, G127, G138,
Services and G144 G139, G150
484.18 Acceptance G157, G158, G159 G160, G162, G163
Of Patients, Plan of Care, G164, G165, G166
484.30 Skilled G170, G172, G173, G169, G179
Nursing Services G174, G175, G176,
484.32 Therapy G186, G187, G188 G190, G193
484.36 Home Health Aide G224, G229 G212, G215, G225, G226, G230
484.48 Clinical Records G236 G239
484.55 Comprehensive G331, G332, G334, G339, G341
Assessment of Patients G445, G336, G337,