Home Health Survey Preparedness

Home Health Survey Preparedness

Survey windows are a source of anxiety for many home health operators. Ensuring your agency is consistently survey ready is imperative for survey success. Surveys must be unannounced, so home health agencies must always be prepared for a surveyor visit. Consider these strategies to ensure survey preparedness…

Top Deficiencies

Deficiencies can be Standard Level, Condition Level or Immediate Jeopardy. Immediate Jeopardy deficiencies can cost your agency $500 – $21,800 fines per day per citation, as well as, immediate termination of the agency.

Top Survey deficiencies for home health according to CHAP (2024) include:

• Plan of Care is not specific to patient needs and does not contain all required elements.
• Visit schedules and frequencies are not met.
• Skilled clinician does not follow Plan of Care as ordered by physician.
• The timeframe is not met for sending transfer and discharge summaries.
• Failure to meet requirements related to the patient’s rights and responsibilities
• Hand hygiene not performed when indicated
• Medication reconciliation not performed
• Failure to perform proper bag technique
• Home Health Aide care plan not followed as ordered by physician
• The agency does not promptly alert the physician or provider related to change in patient condition.

Note: Deficiencies were similar for other accreditations such as The Joint Commission and ACHC.

Key Ways to Prevent Deficiencies

• Remember that the home health survey process is patient-focused and outcomes oriented.

• Ensure the Plan of Care includes all required elements before submission to the physician for signature.
• Review medical records for compliance with physician orders and obtaining orders to update the plan of care when necessary.
• Review all current medications to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.  Ensure that medication reconciliation is completed every visit, by every clinician.
• Ensure the infection control program includes a process for tracking infections and notifying physicians of new infections.
• Ensure the QAPI program includes tracking, trending, and analyzing data in all high-risk areas such as infection control, CoPs requirements and patient outcomes.
• Ensure that all clinicians are properly trained in hand hygiene and bag technique.
• Ensure proper orientation for all new employees including training on the home health Conditions of Participation.
• Provide ongoing training in areas of prior deficiencies, high-risk deficiency areas and areas identified by your agencies QAPI program.

Top 3 Lines of Defense for a Successful Survey

• QAPI
  • Your agency’s QAPI program helps you to proactively identify areas of improvement through ongoing monitoring of agency performance.
  • QAPI facilitates ongoing monitoring of documentation and key areas of focus for agency surveys.
  • Through QAPI, the agency can facilitate needed education based on identified gaps and proactively develop plans of correction.
• Education
  • Standardized orientation, with emphasis on areas of potential survey deficiencies, reduces errors and provides clinicians with the confidence that they need to provide the highest quality of care.
  • Ongoing education for current employees is also essential for continual quality improvement.
• Mock Surveys
• • Allows the team to experience what the survey process will be like to gain confidence in interacting with surveyors while working with Proactive’s mock survey specialists.
  • You get a comprehensive evaluation of your compliance risks and how to address them.
  • You get a summary of your high-risk areas based on current survey trends.

Contact Proactive to schedule your mock survey today!

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