Top Ten ProblemsFound on Survey

MedTrade Spring

Wednesday, April 25, 2007

Mary Ellen Conway, President

Capital Healthcare Group

Top Ten Problems On Survey

Learning Objectives:

• What is the format of a survey?

• How can you prepare?

• What is reality and what is a myth?

• The top 10 problems found and how you can avoid them

Where Do We Begin?

• What is the typical format of the survey?– Now all are unannounced

– Formats• JCAHO Tracer Methodology

• Review of Patient Lists, Personnel Lists, Patients Scheduled for Visits

Two-Day SurveyDay One

Entrance ConferenceInterview of LeadershipReview of Survey Schedule

Review of Patient CensusSelection of Patients to Visit (Close to the Office)Review of Patient Charts (Include those being visiting)

Selection of Employee Charts (or Tracers to Determine)Patient Visits and/or Chart Review

End of Day Wrap up and Plan for Tomorrow

May take Policy/Procedure Manuals, PI Program info to review overnight

More on a Two-Day SurveyDay Two

Review of Day One or items reviewed overnightContinue Patient Chart, Personnel Chart reviewContinue Visits, Staff MeetingsTelephone Interviews

Can Include Referral Sources, Discharged Patients

Review PI programReview minutes of Board Meetings, planning sessions, staff

meetingsExit Conference

Required to mention all recommendations/concerns

Before We Begin

• Ensure that you have worked through your accreditor’s standards– Make sure your policies and procedures are

aligned with the accreditation company’s standards

– You have completed all requirements

CMS Final Quality Standards• Were released on 8-14-06 !!!

• 14 pages—as compared to 104 in September 2005

• Found on the CMS website at: (http://www.) cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp

• Compliance with these standards will be enforced through the accreditation provider you select

#10 Psychotic Surveyors

Myth or Reality?

Is it Myth or Reality?Fact: – You are the accreditor’s

customer– You have ways to appeal– You need to be

prepared!

In Preparation, Create Your Checklist

• Develop your own or purchase one• Check to make sure you have everything

you need on your list– Review your standards/guidelines– Make sure each aspect of your services and

ALL types of services you provide are addressed (retail, delivery, on-line?)

Creating Your Checklist • Warehouse/layout• Educational Calendar• Staff and Patient

Interviews• Infection Control and

Surveillance• Performance

Improvement/QI• Personnel Files• Patient Records• HIPAA• Home Visits

Keep in mind any other compliance that might be assessed, such as HIPAA

Review your entire operation for HIPAA compliance especially:– Customer areas

– Staff areas

– Security of files, billing, patient records, delivery logs, items patients sign

– Shredding?

– Process for sending patient information and receiving referrals and orders

• Example: What’s at your fax machine? Cover Sheet Text?

#9 Everyone Doesn’t Need to Know This Stuff

Myth or Reality?

P.I./Q.I ProgramsPerformance or Quality Improvement

• Usually the one area that organizations have not had in place prior to the pursuit of accreditation

• Can be done internally without outside assistance---but may require benchmarking

• Focuses on item/area that can be monitored and improved (Customer Satisfaction)

P.I./Q.I Programs

• Are Written• Show involvement of staff (as many as

appropriate)• Program is presented, approved and reported on

quarterly• Generally need to show at least 3 months of data

when you submit your application.• Data should be collected, analyzed and acted upon

(all of this is written in the PI Report)

Patient Patient Satisfaction Satisfaction BenchmarksBenchmarks

S Office S Office Mean Mean

D Office D Office Mean Mean

V Office V Office MeanMean

Overall Mean Overall Mean Overall Mean Overall Mean Last Quarter Last Quarter

All Offices All Offices (including B)(including B)

National National MeanMean

Region 3 Region 3 MeanMean

Overall Mean Agency

95.2 87.6 88.6 90.46 88.7 90.0 91.1

Nurses Taught Self Care

95.7 91.3 95.9 94.3 92.3 91.8 92.8

Family Involved in Planning

88.8 89.3 91.7 89.93 85.3 87.2 87.8

Arranging Home Health

89.9 84.8 83.0 85.9 88.1 88.9 89.9

Second Quarter Second Quarter Washington, DivisionWashington, Division

FY 2006FY 2006

2nd Q Data

80

85

90

95

100

S D V Overall Last Q Nat'l Region

Overall Mean Agency

Performance Management1. Beneficiary satisfaction surveys2. Patient complaint log 3. After hours (on call) log to prove

timeliness of response to questions, problems and concerns

4. Log that documents frequency of billing and/or coding errors

5. Log documenting adverse events (as defined by your P & P manual) Most accrediting organizations require at least three months of surveys collected and summarized with plans for improvement or you will have to provide written follow-up and possible a re-visit

Is it Myth or Reality?Fact: – Everyone needs to know

what’s going on– You can not do things in

a vacuum– Everyone needs to be

prepared!

#8 No Ride Alongs?

Bad Idea– Myth!

RealityFact: – There is no insurance issue– If questions are not asked

during the ride, they will be asked at other times

– Practice interviews, safety issues

– Examples

#7 Inventory Management

What is Required?

Final Supplier Quality Standards

2 SectionsFirst Section: Business Services

– Administration– Financial Management– Human Resource Management– Consumer Services– Performance Management– Product Safety– Information Management

CMS Final Quality Standards

Financial Management1. Implement financial management practices that

ensure accurate accounting and billing.

2. Accurate, complete and current financial records

3. Cash or accrual based accounting

4. Link equipment to client

5. Manage revenues and expenses on an ongoing basis:• Reconcile charges with invoices, receipts and deposits

• Operating budget

• Mechanism to track actual revenues and expenses

CMS Final Quality Standards

Product SafetyEquipment management program that promotes the

safe use of equipment and minimizes safety risks and hazards including:

1. Plan for identifying, monitoring and reporting failures, repair and preventive maintenance

2. Investigate any accident or injury (within 72 hours or 24 hours if results in hospitalization or death)

3. Contingency plan for response to emergencies and disasters

RequirementsMust Comply With: – CMS Final Quality

Standards– Your Accreditor’s

Requirements

#6 Competency Program

What is Required?

CMS Final Quality Standards

Human Resource ManagementImplement policies on:

Specific qualifications

Training

Experience

Continuing education requirements

Technical personnel:

Competent

Licensed, certified or registered (and current copies on file)

Competency Program

•Review the requirements of your accreditor and be sure you meet them•Generally only technical staff are required to have competency evaluated•Must be observed for technical staff

Is it Myth or Reality?Fact: – Competency Program

must have been completed before survey

– Can be by job description or by item, or both

– Licensed staff have to review each other

#5 “Red Tape” on the Floor

Myth or Reality?

Is it Myth or Reality?It’s an Urban Legend! – You are held

accountable for following your own Policies and Procedures

#4 Preventive Maintenance

What Do I

Need to Have

Available?

RealityFact: – You need to be able to

explain your program for Preventive Maintenance on appropriate items

• How to identify items in the field that need it

• How to show that it’s been performed appropriately and timely

# 3 Policies and Procedures

A “MUST HAVE” in order to become accredited

My P&P List- Policies you need to review

• Policy and Procedure Manual—At a Minimum:– Patient Admission, Transfer, Discharge– Compliance with all Local/State Requirements

• Supporting evidence attached

– Handling of Equipment– Storage of Equipment– Inventory Control and Management– OSHA and Infection Control– Performance Improvement (P.I.) and Data Collection

***Review the requirements of the company you select**

More of My List

• Employment and Personnel Policies– Include Written Job Descriptions and Org Chart

• Competency Assessment Program

• Sample Contracts-if you use them

• Personnel File for Each Staff Member– Files organized and kept in locked, secure area– Health information, DOB kept separately

Personnel Files

• Personnel File for Each Staff Member– Date of Hire– Evidence of Interview– Background checks– Driver’s License/Driving Record– Signed Job Description and Annual Evals– Signed Orientation Checklist– Competency Evals- on hire and annually

• See the specific requirements for the accreditation program you choose

CMS Final Quality StandardsConsumer ServicesProvide clear instructions on use, maintenance and

potential hazards of item(s)

Provide expected time frame for receipt of delivered item(s)

Verify item/service was received

Provide contact information and options for rental or purchase

Provide information and telephone numbers for customer assistance:Regular business hours, after hours, repair, emergencies

Complete Policy and Procedure Manual

•Must meet the needs and requirements of the accreditation provider you select

•Not worth trying to create on your own at this point

Complete Paperwork for Patients

Such as:•Consent for Treatment/Services•AOB•Third Party Review•HIPAA Information•Disaster/Emergency Preparedness•How to Reach the Office (Hours)

Common Items Found• HR Charts

– Complete– Annual Evaluations– Complete Hep B documentation– Medical/Health Info separated

• Patient Charts– Incomplete documentation of receipt of

paperwork– Forms not witnessed, dated, completed as

indicated

RealityFact: – Your P&P should have

everything you need to meet accreditation guidelines

#2 Infection Control

What Happens?

Infection Control and Surveillance

• Manner in which items

are cleaned, serviced,

stored (clean – dirty)-logs

• Decontamination, OSHA issues,

safety equipment and training

• Reporting of infections: patient or staff

• Personal protective equipment

• Visits/patient contact- handwashing

• Retail- customer rest rooms

What Other Common Infection Control/Safety Issues Are Found?

• Infection Control:– Clean vs. Dirty- Warehouse, trucks– Handwashing

• Chemicals scattered throughout• Labeling/placarding• Fire Drills Conducted Annually• Fire Extinguishers Current• Stacks of forms/Trash• Trucks not clean, up to date on maintenance

RealityFact: – Infection Control is one

of the main tenants of accreditation

– You can not review enough

– A revisit is really the only way to observe if infection control practices are being observed

#1 Lack of Physician Orders

What are the

Most Common

Problems?

Problems

• Oxygen• CPAP• Hospice

RealityFact: – HUGE issue– EASILY addressed

• Prescriptions

• Discharge Orders

• Hospice Standing Orders

Solutions

• PLENTY of Staff Training

• Chart Audits

• Orders

• Conduct Your Own Mock Survey

Home Visits

GO OUT AND SEE WHAT’S HAPPENING!!!

Surveyors will interview patients, asking how they were oriented, how to reach the office, how the services has been, any problems…

Time Issues• Current accreditation programs suggest that

organizations should have at least a 3-month history of performance improvement data collected and be implementing systems prior to an accreditation visit

• Small organizations often take at least 3-4 months to complete a “self-study”

• CMS Deadlines• Most surveys are scheduled at least 1- 2

months in advance

The Most Effective Way to Survive and Thrive in Your

Business is to

Be Prepared

Your Questions…

Thank You!

Mary Ellen Conway

President

Capital Healthcare Group, LLC

Bethesda, MD

301-896-0193

www.capitalhealthcaregroup.com