Written by Dawn Selves, Manager of Clinical Consulting Services, McBee

Surveys must be unannounced, consequently, home health agencies must always be prepared for a surveyor visit. Deficiencies can be Standard Level, Condition Level or Immediate Jeopardy. Immediate Jeopardy deficiencies can assess $500 – $21,800 fines per day per citation as well as immediate termination of the agency!

Immediate Jeopardy deficiencies arise from the potential to cause serious harm or actual serious harm caused to a patient.  The key to citation prevention is to know the Conditions of Participation, and regularly schedule assessments of clinical records, home visits, staff/patient interviews, and follow-up training.

Top 2022 Survey Deficiencies are related to the Plan of Care, Medications, and Infection Control.

Keys to prevent deficiencies

  • Ensure the Plan of Care includes all required elements before submission to the physician for signature.
  • Review medical records for compliance with following physician orders and obtaining orders to update the plan of care as necessary.
  • Review medical records to ensure documentation meets all requirements for complete interim orders and visit notes.
  • Review all medications the patient is currently using 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 the infection control program includes a process for tracking infections, and notifying physicians of new infections, and the QAPI program includes tracking, trending and analyzing infection data. Identify agency infection rate.

Utilizing the agency’s quality assurance and performance improvement (QAPI) plan and mock surveys are the best defense.

  • Performing at least quarterly clinical record review and providing education related to identified needs to staff
  • Timely investigation and record review for all patients that have emergency department visits and/or re-hospitalizations
  • Timely investigation and record review of complaints (Expect a complaint survey with every complaint received)
  • Plan an annual mock survey, including on-site visits and interviews with patients and staff
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