There are New Survey Protocols. Are You Ready? Part 1
(Part 1, the Types of Surveys and Level 1 and Level 2 Citations)
CMS has released a revision of the Home Health Agency Survey Protocols and a New State Operations Manual. The new survey process is data-driven and patient outcome-oriented with less structure yet very process-driven. Surveyor worksheets are presently under development and will be released soon by CMS.
The advanced copy of the surveyor procedures introduces a tiered system that directs surveyors to focus on quality of care vs other operations such as HR files. 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? To read more, please visit: www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf
The survey process is guided by interpretive guidelines and survey protocols established to provide guidance for surveyors. They provide clarity as to intent of the regulations. 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.
Types of Surveys
The survey process provides for a standard survey, a partial extended survey, and an extended survey. All HHA must undergo a standard survey.
The initial certification requires compliance with SS Act1861(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 15CoPs. 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 I 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. The more you know about the new process, the better prepared you will be for your next survey.
Next segment: Surveyors Prep for Survey, Entrance Interviews, Interview Questions They May Ask of Field Personnel and Clinical Managers. Are You Ready?
Partial Extended Survey
|484.10 Patient Rights||G107, G109||G101, G108, G111, G114|
|484.12 Compliance with Federal, State. Local Laws||G121||G118|
|484.14 Organization, Services and Administration||G123, G133, G143,G144||G124, G125, G127, G138,|
|484.18 Acceptance of Patients, Plan of Care, Medical Supervision||G157, G158, G159, G164, G165, G166||G160, G162, G163|
|484.30 Skilled Nursing Services||G170, G172, G173, G174, G175, G176, G177||G169, G179|
|484.32 Therapy||G186, G187, G188||G190, G193|
|484.36 Home Health Aide Services||G224, G229||G212, G215, G225, G226, G230|
|484.48 Clinical Records||G236||G239|
|484.55 Comprehensive Assessment of Patients||G331, G332, G334,G445, G336, G337, G338, G340||G339, G341|