By: Brandy Shifteh, RN, BHSA, MBA, Regulations Compliance Manager, MatrixCare

CMS expects home health agencies (HHAs) to have substantial and continued compliance. With this expectation in mind, you shouldn’t consider site surveys a cyclical event, but should integrate Policies and procedures within your processes and systems to ensure both continuous compliance and a constant state of Survey readiness.

Here are four steps to prepare for your home health survey and how establishing processes can make operations more efficient.

1. Identify your survey response team.

Putting together a solid plan for survey preparedness starts with identifying your core survey response team. Beyond key leadership in the organization, also look for opportunities to develop field and office Staff. The goal should be to devise a survey preparedness plan that will involve staff on all levels and promote a heightened awareness of the importance of creating an organization and will continuously monitor compliance and improve quality.

Start this process by establishing the survey lead — a critical role in the response team who will be the key contact for surveyors and the guide for the rest of the team. The administrator/director, quality manager or clinical manager are often natural choices for this role due to their knowledge about the operations and ability to effectively lead others. Other areas that need roles assigned include:

• Organization and maintenance of survey documents
• Policies and procedures
• Patient safety and emergency preparedness plan (EPP)
• Personnel records, required education and competencies
• Data management, QAPI plan and infection control program
• Clinical care, home visits, field supervision and tracer audits
• Office environment and communications

 2. Understand and organize survey documents.

The best defense is a great offense.  When a surveyor arrives onsite, the first hour tends to be the most intense and anxiety-inducing for staff, as multiple documents and reports will be requested, in addition to patient and personnel records, and the need to urgently schedule field visits with staff for the surveyor(s).

It’s not uncommon for even the most experienced and knowledgeable staff to suddenly forget how reports are run or where important documents are located. HHAs can set the tone for a successful survey and provide great direction for staff, helping to reduce confusion and effectively manage anxiety by being prepared to expediently provide any requested document or report. Here are some of the most common survey documents that might be requested during any phase of a survey:

• Unduplicated admissions for the last 12 months
• Active patient report that identifies SOC/episode dates, primary diagnosis and disciplines provided
• Discharged patients with discharge reason for last 12 months
• Active employees (including contracted staff) with titles and DOH
• List of patients scheduled to be seen for home visits during survey

 3. Review and update policies and procedures.

Policy review is not only an important component of survey preparedness, but also a critical administrative activity, as the purpose of policies and procedures is to provide standardization in daily operational/clinical activities. They bring clarity when dealing with questions and issues that are core to quality care, patient safety, legal liabilities, and regulatory rules/requirements.

HHAs should expect various policies and procedures (administrative/operational and clinical) to be requested during the survey process based on findings as they occur. A great best practice to incorporate into annual review and to promote a consistent state of survey-readiness is to create a “hot list” of common policies requested during surveys and policies that relate to HHA known challenge areas (as identified within your QAPI Program). Each HHA’s “hot list” number may vary, depending on prior surveys and known challenge areas identified.

 4. Prepare staff.

Your plan for preparing for surveys should involve preparation of staff on all levels of the organization. The more prepared staff are, the more confident they become while participating in surveys. Confusion is eliminated, as staff know not only what is expected of them, but also what to expect, which promotes predictable staff behavior and reduces anxiety. Here are some unique ways to prepare:

• Get creative. Hold a “survey survival skills fair” and set up stations for hand hygiene, bag technique, trunk checks, mini-tutorials and scavengers hunts. Have an interview station for practice questions, and set up raffles and prizes to make it fun.
• Plan educational topics for scheduled staff and leadership meetings, focusing on key survey areas that often have deficiencies such as nursing, aide and professional assistant supervision requirements, home health aide services, care planning and care coordination, and patient rights.
• Have emergency preparedness training and make sure that you document testing of the plan and that staff know where it is located/are able to access it.
• Train on your QAPI plan and infection control program (inclusive of COVID-19 policies and procedures). Staff on all levels should know what it entails and be able to speak to it.
• Send out electronic newsletters with survey tips and practice interview Q&As.
• Be visual! Set up visual displays of key performance metrics and QAPI indicators around the office to make sure all staff know what the agency is working on improving.

Request a demo to see for yourself how MatrixCare can help your agency run more efficiently — and ultimately prepare for home health surveys.

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