Surviving Your Home Health Agency Survey: Documentation
Home Health Survey Tips.
We are often asked by our customers for tips and information on how to handle a home health agency survey. HEALTHCAREfirst Enterprise Product Manager, Janel Manning, RN, BSN shares some valuable information on how you can be ready when that time comes. Following is the first in a series of articles regarding surveys.
Your receptionist is sitting at her computer enjoying her morning coffee, and suddenly a well-dressed gray haired woman walks through the door, with her rolling cart and notebook in hand. The woman hands her a business card stating that she is from the state office here to do your survey. A look of panic comes across the young receptionist’s face. She leads the surveyor into the administrative conference room and offers the surveyor a drink. She politely closes the door a little and runs into your office… in a high pitch whispering scream, she says “the surveyor is here!”
Panic then fills the room. You sound the alarm and set out giving the managers a task of setting up a call tree and notifying all field staff that there is a surveyor in house. You catch your breath and casually stroll into the administrative conference room. You are told that this is just your annual review. You are given a list of a million items that the survey will be reviewing in the next 2-3 days, including doing onsite visits with your staff! Panic is definitely starting to hit you now! Here we go, you gather up the troops and get to work gathering up all the information that is needed, doing chart audits in between handing something off to the surveyor.
Have you ever been in this situation before? Survey does not have to be this stressful. I want to go over a few things that surveyor are looking for on a visit and create a checklist for you to get ready for your next state , CAHPS, or Joint Commission survey. You will survive!
These items are always asked for when the surveyor arrives at your building. If you know you are due for a survey, this is a great checklist to start from:
- Administrative appointment form
- Copy of Home Health Agency (state) license
- Liability Insurance Certificates
- Copy of CLIA license (for us and those places the agency takes labs)
- Copy of Occupational License (RN/ PT/ OT/ ST/ MSW, etc) & personnel files for selected employees.
- Limited English Proficient document (identifying your translator)
- P&P approval form
- P&P Transmittals
- Documentation of fire drill
- Documentation of Emergency Prep Drill and Review
- Hazard Vulnerability Assessment (HVA)
- Minutes of Professional Advisory Board Meeting (at minimum yearly)
- Copy of last State Survey Report
- Copy of last Joint Commission or CAHPS survey
- Measure of Success (MOS) from Evidence of Standards Compliance (ESC) and Periodic Performance Review (PPR)
- Copy of your PI quarterly reports
- Copy of your utilization review chart audit findings with improvement plan (action plan)
- Copy of your utilization review minutes with appropriate disciplines
- Copy of Casper (OBQM/ OBQI) reports with findings
- List of all employees with employment status
- Copy of budget
- Copy of unduplicated census
- Number of discharges and discharge reason in the last 12 months
- Will request full charts on any patients that they will selectively go out to visit with a clinician to evaluate care provided. Usually must print this copy or provide computer access. They will also pull additional charts based on a percentage of total census
- Copy of organizational chart structure hanging in the office.
- Copy of administrative policy and procedures.
- Copy of clinical policy and procedures.
But wait there is more! Watch for our next post where we identify some items that are always a good idea to review with your managers and staff prior to a survey.