4/14/2016
[email protected]
www.askFMS.com
PHONE: 800.213.4732
FAX: 866.824.5119
Focus on Success:
Your Next State Survey
DeAnn Briscoe, RN BSN COS-C
Senior Clinical Education Consultant
Foundation Management Services, Inc.
Objectives
• Describe the Conditions of Participation examined by the State
Surveyor in a home health survey.
• List essential actions for agencies to take prior to a State survey.
• Discuss methods which may be utilized to identify agency
vulnerabilities.
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There are two kinds of statistics, the kind
you look up and the kind you make up.
--Rex Stout
Know what they’re
looking for…
Most frequently cited deficiencies for
home health
G-Tag
Subject
Regulation
G158
Acceptance of Patients, Medical Supervision
G133
Administrator
§484.14
G236
Clinical Records
§484.48
G143
Coordination of Patient Services
G159
Plan of Care
§484.18(a)
G321
Encoding OASIS Data
§484.20(a)
G170
Skilled Nursing Services
G337
Drug Regimen Review
§484.55(c)
G144
Coordination of Patient Services
§484.14(g)
G176
Duties of the Registered Nurse
§484.30(a)
Foundation Management Services, Inc.
§484.18
§484.14(g)
§484.30
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OASIS Focus Areas
• Encoding of OASIS data (G321)
• Reporting of OASIS information (G320)
• Transmittal of OASIS data (G323)
Survey Process
• Home Health
• Initial Survey
• 18 months after initial
• Every 3 years
• Complaint investigations as applicable
• Survey tasks
• Pre-Survey preparation
• Entrance interview
• Information gathering
• Information analysis
• Exit conference
• Formation of Statement of Deficiencies
Level 1
Level 2
Highest-Priority Standards
(standard survey)
Next Highest-Priority Standard
(partial extended survey)
G107, G109
G101, G108, G111, G114
G121
G118
484.14 Organization, Services
& Administration
G123, G133, G143,G144
G124,G125,G137,
G138, G139, G150
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
COPs
484.10 Patient Rights
484.12 Compliance w/
Federal, State & Local Laws
484.32 Therapy Services
484.36 Home Health Aide
Services
G186, G187, G188
G190, G193
G224, G229
G212, G215, G225, G226,
G230, G232
484.48 Clinical Records
G236
G239
484.55 Comprehensive
Assessment of Patients
G331, G332, G334, G335,
G336, G337, G338, G340
G339, G341
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Pre-Survey Prep
“oblivious joy” stage
Pre-Survey Preparation
Surveyor Analysis of
Your Agency
• Patient population
• Key issues
• Unique agency
characteristics
Action Items
• Run report of top diagnoses,
disciplines used, types of
patients on service
• Look at OASIS Error Summary
Report, reported outcomes,
Potentially Avoidable Event
reports, etc.
• Examine your agency
Patient Population
• Diagnoses
• Look for your top diagnoses
• Over-utilization of certain ones (favorites)?
• Case-mix
• Ensure primary diagnosis = primary focus for services provided
• Clinical documentation/interventions/goals must support
• F2F must support (initial certification)
• Services provided
• Look at top disciplines utilized
• Types of patients on service
• Where referral originated (facility vs community)
• Chronic vs acute
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Key Issues
• Examine your weak areas
• OASIS
• Error Summary Report by HHA
• Available from Caspar report
• Agency processes for OASIS completion/submission
• Keep a monthly/weekly spreadsheet
• Notify key personnel of error results
• Potential Avoidable Event (PAE) report
• Caspar report
• Agency Characteristics
• Later in the presentation
Key issues (cont)
• Pre-Survey purpose
• Guides surveyor for:
• Selection of patients for clinical record review & home
visits
• Examination of agency processes
• Interview of agency staff
• Generally, help focus survey
Entrance Interview
“Eek” stage
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Entrance Interview
• Focus on agency persons in charge
• Administrator
• Agency Director
• Clinical Managers
Entrance Interview
• Question topics
• Patient Rights (484.10)
• Compliance with Federal, State and local laws, disclosure and
ownership information, and accepted professional standards
and principles (484.12)
• Organization, services, and administration (484.14)
• Acceptance of patients, plan of care, and medical supervision
(484.18)
• Skilled nursing services (484.30)
• Therapy services (484.32)
• Home health aide services (484.36)
• Clinical Records (484.48)
• Comprehensive assessment of patients (484.55)
Patient Rights (484.10)
• How do you facilitate patient/caregiver participation in the plan of
care?
• How are complaints investigated?
• How are complaints documented, investigated and resolved?
• Action:
• At admission, documentation of pt/cg participation in POC
• And, throughout episode when changes in POC occur
• Staff needs to know complaint process
• Texas: must have policy on Abuse, Neglect, & Exploitation selfreporting
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Compliance with Federal, State & Local Laws,
Disclosure & Ownership Information, & Accepted
Professional Standards & Principles (484.12)
• How does your agency ensure that all clinical staff (direct and
contract) follow professional practice standards, laws, HHA polices
and procedures?
• How does your agency monitor the professional skills of your staff to
determine if those skills are appropriate and adequate for the
agency’s patient (e.g. competency testing, supervisory visits, skills
labs, etc.)?
• Action:
• Knowledge of professional practice standards, laws, P&P, regs
• Use of experts
• Clinical record review
• “Ride alongs”
Organization, Services, & Administration (484.14)
• Explain agency organizational structure, lines of authority and
delegation of responsibility and services furnished.
• How are specific patients condition, response to interventions and
teaching changes in the plan of care and discharge planning are
communicated among the appropriate care providers and where
those communications are documented?
• Actions:
• Educate staff on lines of authority and delegation of responsibility
• Ensure staff understands/utilizes care coordination
• Clinical record review
Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Are there any services that the agency sometimes has trouble
staffing, and if so, what do you do when a patient needing those
services is referred?
• Ask administrative staff if the HHA has a policy regarding how quickly
an order for therapy, MSW, or an aide will be staffed.
• Ask clinical supervisors/staff about instances of patient care noted
in home visits or record reviews that deviated from the physician's
orders, accepted professional standards or agency policy.
• Ask how the HHA ensures that verbal orders are accepted, co-signed
by the nurse or therapist and countersigned by the physician
appropriately.
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Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Actions:
• Education of staff regarding services, staffing, policies on
staffing/admission
• Competency of staff to perform special procedures (e.g.,
wound vac, access of ports, lymphedema therapy, etc.)
• Clinical record review
• Review of orders
• Process for submission and return of orders
• Checking of physician signature
• No stamped signatures
• Physician must date
Skilled Nursing Services (484.30)
• How does agency staff RNs and LPNs?
• If HHA relies primarily on LVNs/LPNs for most visits, how does
HHA ensure that RNs supervise and manage each case?
• Actions:
• Ensure LVN/LPNs and RNs understand role in home health
• Clinical record review
• Evidence of care coordination between nurses
• Clear process for management of each case
Therapy Services (484.32)
• Ask how agency staffs therapists and therapy assistants
• How does agency ensure that qualified therapists supervise and manage
each case?
• Actions:
• Understanding of regulations regarding roles of qualified
therapists and assistants
• Clinical record review
• Evidence of care coordination
• Pay special attention to:
• Functional reassessments (13th/19th visits, and at least every 30
day)
• Changes in POC
• Discharges
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Home Health Aide Services (484.36)
• Are aides direct employee of your agency or contract?
• What is your system for tracking aide supervisory visits?
• Actions:
• Ensure good process for timely aide supervisory visits
• Regulation: aide doesn’t have to be present
• Good practice: supervision with aide present on a periodic
basis
• Clinical record review
• Pay special attention to Aide Assignment Care Plan
• Is it up to date? Relevant? What will the patient say about
it?
Clinical Records (484.48)
• Ask if the HHA accepts electronic signatures by either clinicians or
physicians, and what the related policies allow.
• Ask how clinical records are maintained (i.e., all electronic, all paper,
or combination), stored, and accessed.
• How is confidentiality of records maintained out of the office?
• Ask what time frame is allowed for clinicians to turn in
documentation following a visit.
• If there is a stated/published policy, is there a monitoring system
present?
• What are results of internal monitoring?
Clinical Records (484.48)
• Ask what HHA's time frame is for documents to be filed in patient
record.
• Ask where clinicians document aide supervisory visits, case
conferences, phone calls, medications, etc.
• Ask what HHA's policy is for making corrections in the clinical record.
• Actions:
• Know the regs and agency P&P on filing, other documentation,
and corrections
• Ensure staff also knows
• Clinical record review
• Examine processes for documentation of sup visits, case
conferences, phone calls, medications, care coordination, etc.
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Comprehensive Assessment of Patients
(484.55)
• Ask what the HHA's policies are for conducting the initial and
comprehensive assessments (including whether therapists complete
these assessments).
• Ask how the HHA ensures that initial assessments are conducted
within the required time frame.
• Ask what the HHA's policies are regarding drug regimen review.
• If problems with OASIS data submission are evident in the reports
reviewed pre-survey, ask the administrative staff to address those
issues.
• Ask clinical managers & staff to describe their process of drug regimen
review, including how this is accomplished when a therapist completes
the comprehensive assessment.
• Ask clinical managers and staff how they address medication
discrepancies (e.g., what is in the home differs from orders received) or
patient noncompliance.
Comprehensive Assessment of Patients
(484.55)
• Ask clinical managers and staff how they respond to prescriptions
from physicians other than the physician responsible for the patient's
home health care.
• Ask clinical managers and clinicians how they determine when there
has been a "major decline or improvement in the patient's health
status" that would warrant an update of the comprehensive
assessment.
• Ask how HHA tracks due dates for updating the comprehensive
assessments
• Actions:
• Ensure staff knows policies for initial and comprehensive
assessments, time frames for completion and how drug regimen
review is completed when therapist performs admission
• Know difference between M0102 (Date of Physician-ordered
SOC/ROC) and M0104 (Date of Referral)
Comprehensive Assessment of Patients
(484.55)
• Actions (cont):
• Review process of checking on dates of referral compared to SOC
date
• Review process of ensuring meds listed in drug regimen review
are the same as drugs in the home.
• Notification of physician for non-compliance.
• Process for other physicians giving orders
• Process/policy for significant change in condition
• Definition of significant change in condition
• Tracking process of due dates of comprehensive assessments
(recerts, ROCs, discharges)
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General Advice
• Set the tone of the survey
from the start
• Don’t be defensive or
argumentative
• Be receptive and teachable
KEEP
CALM
AND
SURVEY
ON
Information Gathering
“Chew your fingernails” stage
Information Gathering
• Focus:
• Is agency delivering high-quality of patient care with positive
outcomes?
• Does the agency have the ability to deliver needed patient
services?
• Methods:
• Clinical record review
• Home visits
• Interview of field staff and patients
• Should be organized, systematic, and consistent
• Uses a case-mix stratified sample
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Survey Record Reviews
Unduplicated admissions during
recent 12 months
Minimum # of record reviews
with home visits
Less than 150
5
150 – 750
6
751 – 1250
8
1,251 or more
10
34
Additional Survey Record Reviews
Unduplicated admissions during
recent 12 months
Minimum # of record reviews
with NO home visits
Less than 150
5
150 – 750
6
751 – 1250
8
1,251 or more
10
35
Patient Rights (484.10)
• Home Visit (interview of patient/caregiver)
• How did you participate in the planning of your care?
• Have you had any complaints?
• How did you make that complaint known?
• If you had a complaint would you know who to contact?
• Record Review:
• Is there evidence that the patient verbalized complaints and how
the complains were addressed?
• Is there evidence that the patient/caregiver was informed about and
contributed to planning his/her care?
• Paper Compliance:
• Request and review a copy of the HHA documentation of complaint
investigation and resolution
• Review patient admission packet for instructions for making a
complaint
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Patient Rights (484.10)
• Actions:
• Documentation of patient/caregiver participation in POC
• Quote their words
• Document changes in POC have been discussed with
pt/caregiver and their response
• Every visit, ask if patient/caregiver is satisfied with care
• Recognition of complaints and appropriate action
• Avoid documenting complaints in visit notes
• Use agency form for complaints
• Complaint/Grievance log
• Complaint investigation process
• Admission packet must have instructions on complaint process
for patient/caregiver
Compliance with Federal, State and Local Laws, Disclosure
&Ownership Information, & Accepted Professional
Standards & Principles (484.12)
• Home Visit:
• Are there instances of staff providing care not supported by laws,
regulations, state practice acts, accepted professional standards or HHA
policies/procedures (e.g. wound care, prevention of infection, physical
assessment, medication review?)
• Record Review:
• Are there examples of care provision not in compliance with laws,
regulations, accepted professional standards or agency policies and
procedures (e.g., documentation of wound care, wound assessment, or
physical assessment?)
• Paper Compliance:
• If questions arise during interviews, home visits or record reviews,
consider:
• Review agency policies and procedures for the area of interest.
• Identify and review materials that agency provides to staff as clinical
procedural resources.
Compliance with Federal, State and Local Laws,
Disclosure & Ownership Information, & Accepted
Professional Standards & Principles (484.12)
• Actions:
• Ensure staff knows regulations, accepted professional standards and
principles
• Includes OSHA, CDC, State practice acts, etc.
• Documentation reflects above
• Policies and procedures
• Documentation of staff education
• Teaching materials
• Resource information
• Training records for specialized procedures
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Organization, Services, & Administration
(484.14)
• Home Visits:
• How do staff members communicate with patient/caregivers and
identify the need to communicate with other providers?
• When pertinent clinical findings are noted during a visit (e.g. changes
in patient condition, new medication, lab values, updates to the plan
of care etc.), how do you follow up or share the information with the
appropriate team member?
• Is there evidence that the communication plan was implemented?
• Record Review:
• Is information about patient condition, response to interventions (e.g.
medication side effects, responses to wound therapy, and teaching,
etc.) and lab values, changes in the plan of care, and discharge
planning discussed with or forwarded to the appropriate team
members, including home health aide and physician?
• Are case conference, informal conference and phone calls
documented?
Organization, Services, & Administration
(484.14)
• Paper Compliance:
• If questions arise during interview, home visits or record reviews,
consider:
• Review the organizational chart to verify administrator
responses
• Review policies regarding coordination of care, communication
with team members etc.
• Actions:
• Ensure there is documentation of communication
• With patient/caregiver
• Care coordination between disciplines
• Identification of what needs to be communicated
• Problem area: times of informal communication
• Organizational chart must match verbal responses
• Actual line of authority vs “theory of authority”
• Review policies regarding coordination of care and communication
Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Home Visits:
• Did care provider(s) deliver care as ordered and according to
accepted standards (e.g., CDC guidelines) and agency policy?
• Did care provider report any untoward or unexpected patient
changes timely?
• Is the care being provided as the patient was told it would be?
• Record Reviews:
• Did the HHA begin services as ordered, within the specified time
frame, and at the frequency ordered?
• Do plans of care contain all required elements and are they
reviewed by physician every 60 days?
• Are plans of care patient-specific (i.e., contain measurable goals
and instructions for care that are specific to the individual patient)
with stated parameters for measurements where appropriate?
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Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Record Review (cont):
• Is there evidence that physician orders obtained after the
beginning of each 60-day episode of care are documented and
implemented?
• Do clinicians promptly report patient status change, including
variance from any parameters stated in the plan of care?
• Is there evidence of patients denied or not offered needed
services?
• Review records of hospitalized patients to determine if staffing
or scheduling is a problem.
Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Paper Compliance:
• If questions arise during interviews, home visits or record reviews,
consider:
• Review agency policies/procedures regarding obtaining
physician orders, new/additional telephone or verbal orders,
time frames to start ordered therapies and aide services,
reporting patient changes, and specific types of care (e.g.
wound care, IV therapy)
• Review contracts of services provided under arrangement
• Actions:
• Ensure staff knows/follows policies regarding infection control
(bag technique, cleaning of supplies, hazardous waste disposal,
etc.)
• On-site visits periodically with clinicians (before survey)
Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Actions (cont):
• Documentation of communication with other staff and physician
of changes in patient condition
• Education of patient regarding care provided
• Documentation in clinical record and home folder (as
applicable)
• At end of each visit, review care provided with patient
• Clinical record review:
• Care provided
• Orders for care
• Frequency
• 485 (really proofread it!)
• Physician signature/date on 485 and supplemental orders
• Patient specific measurable goals
• Care provided appropriate for patient
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Acceptance of Patients, Plan of Care and
Medical Supervision (484.18)
• Actions (cont):
• Clinical record review (cont)
• Parameters present where appropriate?
• Specific to patient
• Process for clinicians to know established parameters
• Ensure patients are offered/receive needed services
• Documentation of patient refusal or previous service provided
• Record review of patients who are hospitalized
• Were services provided and frequency adequate?
• Were there unheeded warning signs?
• Ensure policies/procedures are present for physician orders, time
frames for initiation of services, reporting of patient changes, and
specific types of care.
• Review contract services
• Most challenging of all employees
Skilled Nursing Services (484.30)
• Home Visits:
• Is care provided as ordered?
• Does clinician follow CDC infection control guidelines, state
practice act, and accepted nursing standards in providing care?
• Does patient/caregiver know what medications patient is
taking and do they match the orders?
• Are patient's needs being met and is patient/caregiver satisfied
with HHA services?
Skilled Nursing Services (484.30)
• Record Reviews:
• Is there evidence that RN is managing and coordinating each
patient’s care:
• Is nursing care provided to each patient as ordered on the plan of
care?
• For patients with co-morbidities, is there evidence that interrelated factors are addressed in managing patient’s care (e.g.
addressing nutrition and skin care in a diabetic patient with a
wound).
• Is there evidence of patient needs that are not addressed in the
plan of care of communicated to the physician?
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Skilled Nursing Services (484.30)
• Paper Compliance:
• If questions arise during interview, home visit or record review,
consider:
• Review specific HHA policies and procedures related to areas of
interest.
• Actions:
• Following POC is primary reason for citations
• How do clinicians know what POC/orders say?
• Ensure there is ongoing medication review
• Check for non-compliance
• At end of each visit, nurse should ask if patient is satisfied with
services.
• Ensure evidence of LVN/LPN reporting to RN for any problems,
concerns, &/or need to change POC
Skilled Nursing Services (484.30)
• Actions (cont):
• If using paper 485, use as tool for completed interventions,
changes in meds, etc.
• Documentation of inter-related factors of co-morbidities
• Notify physician of all concerns and patient needs
• Up to date personnel records with clinicians’ professional
experience, competency, training, etc.
• Avoid coercing clinicians to perform tasks they are reluctant to
perform
Therapy services (484.32)
• Home Visits:
• Is care provided as ordered?
• Does therapist follow CDC infection control guidelines, laws,
regulations HHA policies and procedures and accepted clinical
standards in providing care?
• Ask patient/caregiver if needs are being met and if they are
satisfied with services
• Record Review:
• Are therapy visits made at the frequency ordered?
• Are assessments & communication with other care providers
documented?
• Is therapy provided to each patient as ordered?
• Is there evidence of patient therapy or equipment needs that are
not addressed in the plan of care of communicated to the
physician?
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Therapy services (484.32)
• Paper Compliance:
• If questions arise during interviews, home visits or record reviews,
consider:
• Review specific HHA policies and procedures related to areas of
interest
• Review personnel records of clinicians that appear to provide care
that does not meet laws, regulations, standards & policies.
• Review contracts for service provided under arrangement as needed.
• Actions:
• Same as Skilled Nursing Services
• Evidence of assistants reporting to supervising therapist
• Process for 13th/19th visits and 30-day (at least) functional reassessments
(see next slide for 2013 rules)
• Qualified therapists only
• Billing adjustments for non-covered services
• Patient specific, measurable goals
Therapy Reassessment
• Each therapy must reassess at least every 30 days
• Reassessment by qualified therapist
• Must perform ordered therapy service
• Functionally reassess patient
• Compare resulting measurement to prior assessment
measurements
• Documentation of effectiveness of therapy or lack thereof
• Note: 30-day clock resets with each reassessment of that
discipline
Home Health Aide Services (484.36)
• Home Visits:
• How does aide interact with patient/ caregiver?
• Did aide provide care as described on written instructions?
• Ask patient/caregiver what care the aide provides and whether they
are satisfied with the care.
• Record Reviews:
• Were supervisory visits made every two weeks?
• Did the RN or therapist ever observe the aide’s provision of care?
• Was aide instructed in any clean dressing changes or other
specialized procedures?
• Was aide’s care provided according to the written instructions and
the physician orders?
• Were written instructions provided to the aide specific to the
patient?
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Home Health Aide Services (484.36)
• Paper Compliance:
• If questions arise during interviews, home visits or record review,
consider:
• Review agency policies regarding development of aide
instructions and aide supervision
• Review aide personnel records
• Review contracts if aide services are provided under
arrangement
• Actions:
• Periodic on-site visit with aide present
• Review of aide instructions (care plan) at least every 14 days
• Questioning of patient/caregiver on care provided
• Ask patient/caregiver if satisfied at end of each visit
Home Health Aide Services (484.36)
• Actions (cont):
• Clinical record review of aide supervisory visits
• Frequency per regulations
• If not, examine process for scheduling; write Performance
Improvement plan
• Clinical record review of care provided by aide and written
instructions
• Patient specific
• RN or qualified therapist (if no skilled nursing services ordered)
• Delegation of simple tasks
• Documentation
• On-site instructions with return demonstration
• Examine policies regarding aide instructions & supervision
• Examine personnel records of aides
• Training, deemed competency, etc.
Clinical Records (484.48)
• Home Visits:
• Are medications in home the same as those listed on plan of care,
interim orders and the clinical record notes?
• Is patient status, care provided and medications the same as that
documented in the record?
• How does agency staff maintain the confidentiality of protected
health information kept in the home?
• Record Review:
• If record seems incomplete, note the date of the latest filing in
records and ask about any documentation waiting to be filed.
• Do clinicians consistently document vital signs; insulin injections;
blood glucose measurements; wound appearance, location(s) and
treatment; and pain location(s), frequency, severity, interventions,
& response to interventions?
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Clinical Records (484.48)
• Record Review (cont):
• Are comprehensive assessments complete?
• Are medications on plan of care, medication list (if applicable),
and visit notes the same?  How are corrections made in
clinical record? Is there evidence of different handwriting in the
record signed by the same clinician? Were different inks used
for the same note?
• Do records of discharged patients contain discharge
summaries?
• Do records contain periodic summaries of patient care that
were sent to physicians?
Clinical Records (484.48)
• Paper Compliance:
• If questions arise during interviews, home visits or record reviews,
consider:
• Review HHA policies on documentation, clinicians' time frame
for turning in documentation after visits, and time frame for
filing documentation. Can the agency provide tracking reports?
• Investigate HHA procedure(s) for making corrections when
assessment submitted for data entry of OASIS items is
incomplete and check for evidence that changes made to
OASIS item responses were submitted to the State.
• Review HHA's OASIS data transmittal records.
• Actions:
• Ensure clinical record is consistent with reality of patient
• Educate on maintaining confidentiality in home, during visits, etc.
Clinical Records (484.48)
• Actions (cont):
• When surveyor arrives in agency, start filing any documents
waiting to be filed
• Don’t hand over any patient record until filing is checked and
there has been a quick check of chart.
• Clinical record review
• Completeness of charting (skilled interventions, response to
interventions, full assessment and anything specified in orders)
• Review policy on corrections and assess clinicians’ practice
• Surveyors/audit entities suspicious of different ink, lots of late
entries, different handwriting
• Discharge summaries for all patients discharged
• 60-day summaries
• OASIS correction process
• OASIS data transmittal processes
• New RAC audit item (semi-automatic)
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Comprehensive Assessment of Patients (484.55)
• Home Visits:
• Ask the patient/caregiver what medications the patient is
currently taking and compare those with the orders, medications
in the clinical record.
• Ask patient/caregiver about the course of their episode of home
care, whether there have been setbacks or problems and how the
HHA has addressed them.
• Ask patient/ caregiver is they are concerned about problems that
have not been addressed by HHA staff to their satisfaction.
• Record Reviews:
• If the initial assessment occurred more than 48 hours after the
referral was received, was the discrepancy explained (physician
ordered, patient request approved by physician)?
• Are comprehensive assessments completed on time and by the
appropriate clinician during a home visit at start of care, within 48
hours of (or knowledge of) patient's return home from an
inpatient stay, every 60 days (or more frequently), and at
discharge?
Comprehensive Assessment of Patients (484.55)
• Record Reviews (cont):
• If a record indicates that a patient had a "major decline or
improvement," was the comprehensive assessment updated?
• Do records show consistency in assessment of patient's status and
progress over many visits (e.g., wounds in consistent locations,
patient weights seem logical, pain management, presence of Foley
catheter, etc.)?
• Paper Compliance:
• If questions arise during interviews, home visits or record reviews,
consider:
• Review HHA's policies for conducting the initial and
comprehensive assessments, drug regimen review, including
therapy only cases and when medications are changed after
the start of care.
Comprehensive Assessment of Patients (484.55)
• Paper Compliance (cont)
• Review HHA's policy defining a "major decline or improvement
in the patient's health status" that would warrant an update of
the comprehensive assessment.
• Review HHA's orientation program for new skilled clinicians,
particularly those who are new to home care
• Actions:
• Multiple questions asked about drug regimen review matching
meds in home…beware!
• Examine process for comprehensive assessments / SCICs
• Assess patient/caregiver satisfaction
• Timely initiation of care
• Run reports
• Clinical record review
• Education to clinicians, auditors, data entry
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Comprehensive Assessment of Patients (484.55)
• Actions:
• Clinical record review for consistent, logical documentation
• Consistent with OASIS documentation?
• Review of policies on comprehensive assessments, drug regimen
review, changes in medications, major decline/improvement
• Examine orientation program for nurses new to home health, new
to certain skills, etc.
• Should look different than orientation for seasoned home
health nurses
Information Analysis
“Good gosh, when is she going to leave!” stage
Information Analysis
• Analyzes findings related to each requirement for:
• Effect or potential effect on patient care outcomes;
• Degree of severity;
• Frequency of occurrence;
• Impact on delivery of services
• Results of analysis:
• Possible extended survey;
• Citing of condition-level deficiencies;
• Further investigation for related conditions
• Based on specific recommendations from SOM
• Action items:
• Designate agency person to record all charts audited, patients visited,
surveyor questions, requested documents, interviewed clinicians, etc.
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Exit Conference
“Sigh of relief or Let’s rumble” stage
Exit Conference (no surprises)
• Purpose:
• Inform of observations and preliminary findings
• Attendees:
Administrator, clinical managers, and other staff members (as
desired)
• Conference content:
• Regulatory requirements not met by the agency
• Allow questions/additional information regarding findings
• Education in response to agency questions
• Clarify areas for possible further deficiencies after surveyor
consults with program manager
• Education on form CMS-2567 no later than 10 working days after
exit conference
• Instructions and time frame for submission of plan of
correction
Formation of Statement of Deficiencies /
Violations
“worry mixed with relief” stage
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Formation of Statement of Deficiencies /
Violations
• What is involved:
• Analysis of:
• Interviews
• Home visits
• Documentation
• Compliance to standards
• Program Manager review
Plan of Correction
“are you serious????” stage
Plan of Correction Components
• Determine reason/source of deficiency
• Read CoP and interpretative guidelines
• What is the intent and how do you meet it?
• What problem was identified by surveyor?
• Where did the failure occur?
• Agency-wide
• Individual clinician
• What evidence was listed by surveyor?
• Plan of Correction for each cited deficiency and violation
• Even if requesting informal review of deficiencies (IRoD)
• Must be typed or legibly written in black ink in second
column of Statement of Deficiencies
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Plan of Correction Components
• PoC (cont)
• Components:
• Responsible person
• Title of person (no proper names)
• Plan for correction
• Includes monitoring for ongoing compliance
• How plan will be implemented
• Examples: training, clinical record review
• How often it will occur
• Consequences of non-compliance by staff
• Don’t make it harder than it needs to be
• When will problem be corrected
• Earliest acceptable date is day after survey completed
• Different severities have different time frames for
completion
• Submit within 10 calendar days
Agency Patient-Related Characteristics Report
Previously called “case-mix report”
Patient-Related Characteristics Report
• Surveyor uses information to get a picture of your agency’s
patients
• Demographics
• General health status
• Living arrangements/assistance
• Care management needs
• Status of body systems
• Diagnostic info
• Length of stay
• Reasons for emergent care & hospitalization
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Use of This Report
• Disease management education
• Care path development
• Need for additional policies/procedures/protocols
• Care coordination needs
• Staffing
• OASIS training for accurate answers
Potentially Avoidable Event Report
Previously called Adverse Event Report
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Potentially Avoidable Event (PAE) Report
• Indicators for potential problems in care
• Measurable change in health status such as # of pressure ulcers
• Change in health status and support available to the patient at
discharge (unmet need) such as discharged to community with
behavioral problems
• Must be investigated to determine root cause
• Measured from OASIS data at SOC/ROC to DC/Death at
home/Transfer to inpatient facility
• Some episodes are excluded from analysis
• Name of patient listed so agency may investigate
PAE
• Surveyor examines 8 of the 12 PAE for the most recent quarter, or
longer if necessary to reach 60 patients
• May require record review, home visits, or both
• Tier 1
• Emergent care for injury caused by fall or accident at home
• 1-2 record reviews and 1-2 home visits with record review
• Emergent care for wound infections, deteriorating wound status
• 1-2 record reviews and 1-2 home visits with record review
PAE: Tier 2
• Surveyor looks for patient with listed PAE outcomes. If none…
• Surveyor examines Graphical PAE report
• If current PAE item (white bar) is 2x > national reference PAE (black bar),
surveyor may focus on those
• PAE items
• Emergent care for improper med admin, med side effects
• Record review plus home visit
• Emergent care for hypo/hyperglycemia
• Record review plus home visit
• Substantial decline in ≥ three activities of daily living
• Record review
• Discharged to the community needing wnd care or med assistance
• Record review
• Discharged to the community needing toileting assistance
• Record review
• Discharged to the community with behavioral problems
• Record review
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PAE
• Now what?
• Know what triggers these items
• Examine/use worksheet to examine each or prioritized PAE
• Clinical record review (visit notes leading up to occurrence)
• Utilize chart audit tool
• Educate clinicians as needed
• OASIS
• Care provision
• Change processes as needed
• Initiate Performance Improvement (PI) Plan as needed
• Implement improvement plan in agency
• Continued review of subsequent PAE reports
• Evaluation of whether PI plan/education is effective
Performance Improvement (PI) Plan
• Statement of problem
• Agency expectations for best practices to occur in the future
• Action strategies
• Methods to monitor and evaluate initiated strategies
• Who will conduct monitoring activities
OBQI Outcome report
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OBQI Outcome Report
• Surveyor selects a maximum of two of ten (sample size of at least
30 eligible cases/last 12 month period):
• Improvement in upper body dressing (≥ 10% lower)
• Improvement in bathing (≥ 10% lower)
• Improvement in transferring (≥ 15% lower)
• Improvement in ambulation/locomotion (≥ 7% lower)
• Improvement in mgmt of oral medications (≥ 10% lower)
• Improvement in dyspnea (≥ 15% lower)
• Improvement in urinary incontinence (≥ 20% lower)
• Acute care hospitalization (≥ 10% higher)
• Improvement in pain interfering with activity (≥ 15% lower)
• Improvement in status of surgical wounds (≥ 10% lower)
• Other
Submission Statistics
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OASIS Submission
• Most recent 6-month period
• Is agency submitting data less often than monthly?
• §484.20: HHAs must, at least monthly, electronically report OASIS
data on all applicable patients…”
• RAC focus area with “look-back” of 1-4 years
• Does agency have >20% rejected records?
• If yes to either question, surveyor will look at:
• Policies/procedures for receiving, tracking, data entering and
transmitting OASIS data and correcting clinical records
• Does the agency follow their P&P
OASIS Submission (cont)
• Another organization or vendor performing this for the agency?
• Written contract?
• Feedback reports provided to the agency?
• Validation report printout requested for 4-6 records reviewed
• Surveyor assessing if agency can provide reports
• Was at least one assessment per record (e.g., SOC, F/U,
Discharge) received by the State?
• High percentage of rejected records?
• Legitimate reason? (large batch submitted twice and all
records in second batch were rejected)
• Can agency verify that its software conforms to CMS
standards?
OASIS Submission (cont)
• Actions:
• Periodic review of OASIS submission errors
• Must correct any errors and still submit within the 30 day
time period
• Ensure policies/procedures in place
• Examine agency processes
• Is there a reason OASIS is not being submitted/rejected?
• Electronic OASIS is “reserved” to a clinician
• Beneficiary information is incorrect
• Submit before the 30th day
• Ensure more than one person knows this process
• Document legitimate reasons for errors
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Error Summary Report
Error Summary Report
• Surveyor examining most recent 6-month period
• Error 286 (Inconsistent Lock date) (warning)
• Inconsistent M0090/Submission date: The submitted
assessment was not submitted within CMS timing
guidelines. The submission date is more than 30 days from
the M0090 (completion date).
• Should be ≤ 19%
• Error 262 (Inconsistent M0090 date; RFA 4 must be done on an
every 60-day cycle) (warning
• Inconsistent M0090 date; RFA 04 (M0090) does not meet
cms timing guidelines. RFAs 04 must be done on an every
60-day cycle; (M0090) is no earlier than day 56 and no later
than day 60 of that F/U cycle.
• Should be ≤ 19%
Error Summary Report
• Error 1003 (Inconsistent effective date sequence) (warning)
• Inconsistent effective date sequence: Record does not meet
sequence guidelines. Effective date of this record submitted
is a date earlier than effective date of the most current
record in the system.
• Should be ≤ 9%
• Error 1002 (Inconsistent record sequence) (warning)
• Inconsistent record sequence: the submitted record does
not satisfy the sequence guidelines. The submitted
(M0100) doe not logically follow the (M0100) previously
accepted by the state system.
• Should be ≤ 9%
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Error Summary Report
• Actions:
• Examine processes for OASIS lock requirement of 30 days
• Assessment must be completed, reviewed, corrected as
needed, and data entered and locked within 30 days.
• Used to be 7 days
• Good practice is submission more often than monthly
• Examine process for scheduling recert assessments between
day 56-60.
• Surveyor will ask how the agency notifies the clinician of
upcoming recerts and how they ensure timely completion
• Examine process for submission of complete patient episodes
(SOC/ROC and corresponding Transfer or DC assessments)
• Note: quality episodes are different than PPS episodes
“Not everything that is faced can be changed.
But nothing can be changed until it is faced.”
--James Arthur Baldwin
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Questions???
[email protected]
www.askFMS.com
PHONE: 800.213.4732
FAX: 866.824.5119
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