Survey readiness is a crucial element in ensuring your home health agency is successful. 

Being prepared for an on-site survey can save your agency from high-level citations to loss of accreditation. It’s more important than ever for home health agencies to be ready for the survey process.

To be prepared, providers will need to be armed with strategies that will help them come out on top.

Here are some strategies on how to help your home health agency be survey-ready at all times:

1. Have a Plan in Place

Ensure you have a team in place to handle the survey, including someone who is well-versed in compliance regulations.

Conduct mock surveys or reviews to identify any areas that need improvement and address them with urgency. This will help your agency assess if your policies and procedures are compliant with the Conditions of Participation (CoP) and identify any areas that require further development.

• Develop a plan for handling surveys and reviews

• Identify team members responsible for handling surveys and reviews

• Conduct mock surveys or reviews to identify areas for improvement

• Implement corrective actions to address identified issues

• Review and update the plan regularly to ensure it remains current and effective

2. Conduct Regular Internal Audits

Conducting internal audits on a regular basis is a proactive approach to ensuring compliance with regulations and standards. Conducting audits will identify areas that need improvement and allow you to make the necessary changes before a survey or review. 

• Look over patient charts to ensure they are complete and accurate

• Review billing practices to ensure claims are submitted timely and accurately

• Check staff compliance with infection control policies and procedures

• Ensure staff members are meeting continuing education requirements

• Review compliance with HIPAA regulations

• Check, schedule, and conduct emergency preparedness drills.

3. Train Staff Regularly

Staff training is a crucial element in ensuring compliance and readiness for surveys and reviews. Regular training will help staff members stay up to date with regulatory changes and stay compliant with regulations. 

Make sure your staff understands the importance of proper documentation, timely submission of claims, and accurate billing. It is important that the entire staff has a strong understanding of the current home health conditions of participation (CoPs) and of policy and procedure changes specific to your agency.

• Plan for routine training sessions with staff and leaders, 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.

• Educate staff members on proper documentation procedures

• Conduct training on billing and coding practices

• 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.

• Train staff members on OASIS assessments and documentation

• Schedule training sessions on the use of electronic medical record (EMR) systems

4. Maintain Accurate Documentation

Accurate documentation is crucial for both surveys. Documentation should be thorough, complete, and timely. 

Make sure staff members understand the importance of accurate documentation and are trained on proper documentation procedures.

• Train staff members on proper documentation procedures

• Implement policies and procedures for documentation to ensure accuracy and completeness

• Use electronic medical records (EMR) at the point-of-care systems to improve documentation accuracy and accessibility

• Conduct periodic audits of documentation to ensure compliance with regulations

• Ensure staff members understand the importance of documentation accuracy and completeness

• Consider bringing in outside experts to serve as extra sets of eyes to review the accuracy of your charts

5. Prepare necessary documents and requirements

By preparing for the survey in advance and having all the necessary documents and information readily available, the accreditation survey process can be made easier and smoother.

To prepare for an accreditation survey, follow these steps:

• Obtain a list of requirements from the accrediting body or state agency before the survey.

• Compile all necessary documents and information into a binder to have them ready for the surveyor.

Documents to include may include the following:

• A copy of current applicable licenses or permits

• A current CMS-855A/CMS approval letter

• The agency’s organizational chart

• Administrator and designee names and letters of appointment

• The organization’s current unduplicated patient census

• Discharge/transfer patient census for the last 6-12 months

• EMR access

Ensure that the documents and information are up-to-date.

• Prioritize EMR access to avoid waiting for access during the survey.

• A bound or electronic copy of your completely ratified Policy and Procedure Manual.

6. Implement a visit notes quality assurance process

By implementing a quality assurance process for visit notes, home health agencies can ensure that your documentation meets regulatory standards and is ready for review during these processes. 

This can help you avoid potential citations or sanctions and demonstrate that you are providing high-quality care to your patients.

• Establish a process for reviewing and assessing the quality of visit notes that are written by your field clinicians

• Provide training and support to staff members to ensure that they are properly documenting patient care in their visit notes

• Identify key quality indicators and establish benchmarks for what constitutes high-quality visit notes

• Assign staff members to regularly review visit notes for accuracy, completeness, and compliance with relevant policies and procedures

• If possible, build or outsource a team dedicated to daily audits of visit notes for a more real-time QA process

• Use feedback from the visit notes quality assurance process to identify areas for improvement and provide ongoing training and support to staff members.

Key Takeaways

Being survey-ready is critical for the success of your home health agency. These strategies can help ensure your agency is prepared. Remember, survey readiness is an ongoing and ever-evolving process. When preparing for a survey, it is important to focus on key areas such as the record review process, staff training, and documentation processes.

It’s crucial to be proactive and prepared so that you can ensure that your agency will be able to continue giving your patients quality care.  

Get a free trial to see how QAnnovate can help your agency prepare for home health surveys.