Learn about the new CoPs and how home health agencies can prepare for upcoming surveys

With the Centers for Medicare & Medicaid Services (CMS) release of the updated Conditions of Participation (CoPs) in the beginning of 2018, it is more important now than ever for agencies to assess their compliance plan.  The new CoPs introduced the Infection Control Program, QAPI Program, Emergency Preparedness, and modifications to current CoPs. Surveyors will look to see if agencies have successfully introduced these new changes into their plans, as well as policies and procedures – paying special attention to the standards that relate to the highest quality patient care.

Survey Process

Surveyors will prepare for the agency survey by running 3 reports to focus on potentially avoidable events. These events will help identify areas of concern and provide a sample of records to choose from for review. Surveyors will review a sample of active records, active records with home visits, and discharged records based on the admissions for the prior 12 months. Surveyors will look at a select number of standards most related to high-quality patient care for a survey that will address 8 of the 13 standards. Surveyors will look at Level 2 standards when further investigation is needed due to a citation of a Level 1 standard.

What Surveyors will Focus On

When conducting surveys, surveyors will specifically focus on the following areas:

  • Adaptation of the CoPs into policies and procedures
  • Care planning and coordination
  • Designation of administrator and designee when administrator is absent
  • Competency of contracted staff

Watch our video to learn more about these focus areas:

How Agencies can Prepare for Surveys

Agencies should take a continual approach to compliance when preparing for surveys. Perform a mock survey to discover gaps or areas where improvement is needed. Then, create an action plan based on the results of the survey.

Annual reviews of procedures and plans, such as the emergency preparedness and infection control program, should be held to check for compliance. Educational sessions for staff should be conducted annually and provide the staff with sufficient information to make them knowledgeable of any new plans or policies. Managers should oversee staff in the field and monitor their performance to ensure their competence in providing patients with high quality care while staying compliant.

Mock surveys are one of the most important ways to prepare for surveys. If agencies continually work on being prepared for a survey at any time, then when a surveyor shows up, they will mitigate risk of repeat deficiencies and be survey ready.