Survey Protocols 2016 · G321 EncodingOASIS Data §484.20(a) G170 SkilledNursing Services §484.30...

4/14/2016

Foundation Management Services, Inc. 1

[email protected]

www.askFMS.com

PHONE: 800.213.4732

FAX: 866.824.5119

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DeAnn Briscoe, RN BSN COS-C

Senior Clinical Education Consultant

Foundation Management Services, Inc.

Objectives

• Describe the Conditions of Participation examined by the State Surveyor in a home health survey.

• List essential actions for agencies to take prior to a State survey.

• Discuss methods which may be utilized to identify agency vulnerabilities.

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There are two kinds of statistics, the kind you look up and the kind you make up.

--Rex Stout

Know what they’re looking for…

Most frequently cited deficiencies for home health

G-Tag Subject Regulation

G158 Acceptance of Patients, Medical Supervision §484.18

G133 Administrator §484.14

G236 Clinical Records §484.48

G143 Coordination of Patient Services §484.14(g)

G159 Plan of Care §484.18(a)

G321 Encoding OASIS Data §484.20(a)

G170 Skilled Nursing Services §484.30

G337 Drug Regimen Review §484.55(c)

G144 Coordination of Patient Services §484.14(g)

G176 Duties of the Registered Nurse §484.30(a)

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OASIS Focus Areas

• Encoding of OASIS data (G321)

• Reporting of OASIS information (G320)

• Transmittal of OASIS data (G323)

Survey Process

• Home Health

• Initial Survey

• 18 months after initial

• Every 3 years

• Complaint investigations as applicable

• Survey tasks

• Pre-Survey preparation

• Entrance interview

• Information gathering

• Information analysis

• Exit conference

• Formation of Statement of Deficiencies

9

COPsLevel 1

Highest-Priority Standards

(standard survey)

Level 2Next Highest-Priority Standard

(partial extended survey)

484.10 Patient Rights G107, G109 G101, G108, G111, G114

484.12 Compliance w/

Federal, State & Local LawsG121 G118

484.14 Organization, Services

& AdministrationG123, G133, G143,G144

G124,G125,G137,

G138, G139, G150

484.18 Acceptance of

Patients, Plan of Care,

Medical Supervision

G157, G158, G159, G164,

G165, G166G160, G162, G163

484.30 Skilled Nursing

Services

G170, G172, G173, G174,

G175, G176, G177G169, G179

484.32 Therapy Services G186, G187, G188 G190, G193

484.36 Home Health Aide

ServicesG224, G229

G212, G215, G225, G226,

G230, G232

484.48 Clinical Records G236 G239

484.55 Comprehensive

Assessment of Patients

G331, G332, G334, G335,

G336, G337, G338, G340G339, G341

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Pre-Survey Prep“oblivious joy” stage

Pre-Survey Preparation

Surveyor Analysis of

Your Agency

• Patient population

• Key issues

• Unique agency characteristics

Action Items

• Run report of top diagnoses, disciplines used, types of patients on service

• Look at OASIS Error Summary Report, reported outcomes, Potentially Avoidable Event reports, etc.

• Examine your agency

Patient Population

• Diagnoses

• Look for your top diagnoses

• Over-utilization of certain ones (favorites)?

• Case-mix

• Ensure primary diagnosis = primary focus for services provided

• Clinical documentation/interventions/goals must support

• F2F must support (initial certification)

• Services provided

• Look at top disciplines utilized

• Types of patients on service

• Where referral originated (facility vs community)

• Chronic vs acute

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Key Issues

• Examine your weak areas

• OASIS

• Error Summary Report by HHA

• Available from Caspar report

• Agency processes for OASIS completion/submission

• Keep a monthly/weekly spreadsheet

• Notify key personnel of error results

• Potential Avoidable Event (PAE) report

• Caspar report

• Agency Characteristics

• Later in the presentation

Key issues (cont)

• Pre-Survey purpose

• Guides surveyor for:

• Selection of patients for clinical record review & home visits

• Examination of agency processes

• Interview of agency staff

• Generally, help focus survey

Entrance Interview“Eek” stage

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Entrance Interview

• Focus on agency persons in charge

• Administrator

• Agency Director

• Clinical Managers

Entrance Interview

• Question topics

• Patient Rights (484.10)

• Compliance with Federal, State and local laws, disclosure and ownership information, and accepted professional standards and principles (484.12)

• Organization, services, and administration (484.14)

• Acceptance of patients, plan of care, and medical supervision (484.18)

• Skilled nursing services (484.30)

• Therapy services (484.32)

• Home health aide services (484.36)

• Clinical Records (484.48)

• Comprehensive assessment of patients (484.55)

Patient Rights (484.10)

• How do you facilitate patient/caregiver participation in the plan of care?

• How are complaints investigated?

• How are complaints documented, investigated and resolved?

• Action:

• At admission, documentation of pt/cg participation in POC

• And, throughout episode when changes in POC occur

• Staff needs to know complaint process

• Texas: must have policy on Abuse, Neglect, & Exploitation self-reporting

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Compliance with Federal, State & Local Laws, Disclosure & Ownership Information, & Accepted Professional Standards & Principles (484.12)

• How does your agency ensure that all clinical staff (direct and contract) follow professional practice standards, laws, HHA polices and procedures?

• How does your agency monitor the professional skills of your staff to determine if those skills are appropriate and adequate for the agency’s patient (e.g. competency testing, supervisory visits, skills labs, etc.)?

• Action:

• Knowledge of professional practice standards, laws, P&P, regs

• Use of experts

• Clinical record review

• “Ride alongs”

Organization, Services, & Administration (484.14)

• Explain agency organizational structure, lines of authority and delegation of responsibility and services furnished.

• How are specific patients condition, response to interventions and teaching changes in the plan of care and discharge planning are communicated among the appropriate care providers and where those communications are documented?

• Actions:

• Educate staff on lines of authority and delegation of responsibility

• Ensure staff understands/utilizes care coordination


Acceptance of Patients, Plan of Care and Medical Supervision (484.18)

• Are there any services that the agency sometimes has trouble staffing, and if so, what do you do when a patient needing those services is referred?

• Ask administrative staff if the HHA has a policy regarding how quickly an order for therapy, MSW, or an aide will be staffed.

• Ask clinical supervisors/staff about instances of patient care noted in home visits or record reviews that deviated from the physician's orders, accepted professional standards or agency policy.

• Ask how the HHA ensures that verbal orders are accepted, co-signed by the nurse or therapist and countersigned by the physician appropriately.

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• Actions:

• Education of staff regarding services, staffing, policies on staffing/admission

• Competency of staff to perform special procedures (e.g., wound vac, access of ports, lymphedema therapy, etc.)


• Review of orders

• Process for submission and return of orders

• Checking of physician signature

• No stamped signatures

• Physician must date

Skilled Nursing Services (484.30)

• How does agency staff RNs and LPNs?

• If HHA relies primarily on LVNs/LPNs for most visits, how does HHA ensure that RNs supervise and manage each case?

• Actions:

• Ensure LVN/LPNs and RNs understand role in home health


• Evidence of care coordination between nurses

• Clear process for management of each case

Therapy Services (484.32)

• Ask how agency staffs therapists and therapy assistants

• How does agency ensure that qualified therapists supervise and manage each case?

• Actions:

• Understanding of regulations regarding roles of qualified therapists and assistants


• Evidence of care coordination

• Pay special attention to:

• Functional reassessments (13th/19th visits, and at least every 30 day)

• Changes in POC

• Discharges

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Home Health Aide Services (484.36)

• Are aides direct employee of your agency or contract?

• What is your system for tracking aide supervisory visits?

• Actions:

• Ensure good process for timely aide supervisory visits

• Regulation: aide doesn’t have to be present

• Good practice: supervision with aide present on a periodic basis


• Pay special attention to Aide Assignment Care Plan

• Is it up to date? Relevant? What will the patient say about it?

Clinical Records (484.48)

• Ask if the HHA accepts electronic signatures by either clinicians or physicians, and what the related policies allow.

• Ask how clinical records are maintained (i.e., all electronic, all paper, or combination), stored, and accessed.

• How is confidentiality of records maintained out of the office?

• Ask what time frame is allowed for clinicians to turn in documentation following a visit.

• If there is a stated/published policy, is there a monitoring system present?

• What are results of internal monitoring?


• Ask what HHA's time frame is for documents to be filed in patient record.

• Ask where clinicians document aide supervisory visits, case conferences, phone calls, medications, etc.

• Ask what HHA's policy is for making corrections in the clinical record.

• Actions:

• Know the regs and agency P&P on filing, other documentation, and corrections

• Ensure staff also knows


• Examine processes for documentation of sup visits, case conferences, phone calls, medications, care coordination, etc.

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Comprehensive Assessment of Patients (484.55)

• Ask what the HHA's policies are for conducting the initial and comprehensive assessments (including whether therapists complete these assessments).

• Ask how the HHA ensures that initial assessments are conducted within the required time frame.

• Ask what the HHA's policies are regarding drug regimen review.

• If problems with OASIS data submission are evident in the reports reviewed pre-survey, ask the administrative staff to address those issues.

• Ask clinical managers & staff to describe their process of drug regimen review, including how this is accomplished when a therapist completes the comprehensive assessment.

• Ask clinical managers and staff how they address medication discrepancies (e.g., what is in the home differs from orders received) or patient noncompliance.


• Ask clinical managers and staff how they respond to prescriptions from physicians other than the physician responsible for the patient's home health care.

• Ask clinical managers and clinicians how they determine when there has been a "major decline or improvement in the patient's health status" that would warrant an update of the comprehensive assessment.

• Ask how HHA tracks due dates for updating the comprehensive assessments

• Actions:

• Ensure staff knows policies for initial and comprehensive assessments, time frames for completion and how drug regimen review is completed when therapist performs admission

• Know difference between M0102 (Date of Physician-ordered SOC/ROC) and M0104 (Date of Referral)


• Actions (cont):

• Review process of checking on dates of referral compared to SOC date

• Review process of ensuring meds listed in drug regimen review are the same as drugs in the home.

• Notification of physician for non-compliance.

• Process for other physicians giving orders

• Process/policy for significant change in condition

• Definition of significant change in condition

• Tracking process of due dates of comprehensive assessments (recerts, ROCs, discharges)

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General Advice

• Set the tone of the survey from the start

• Don’t be defensive or argumentative

• Be receptive and teachable

KEEP

CALM

AND

SURVEY

ON

Information Gathering “Chew your fingernails” stage

Information Gathering

• Focus:

• Is agency delivering high-quality of patient care with positive outcomes?

• Does the agency have the ability to deliver needed patient services?

• Methods:


• Home visits

• Interview of field staff and patients

• Should be organized, systematic, and consistent

• Uses a case-mix stratified sample

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Survey Record Reviews

Unduplicated admissions during

recent 12 months

Minimum # of record reviews

with home visits

Less than 150 5

150 – 750 6

751 – 1250 8

1,251 or more 10

34

Additional Survey Record Reviews

Unduplicated admissions during

recent 12 months

Minimum # of record reviews

with NO home visits

Less than 150 5

150 – 750 6

751 – 1250 8

1,251 or more 1035


• Home Visit (interview of patient/caregiver)

• How did you participate in the planning of your care?

• Have you had any complaints?

• How did you make that complaint known?

• If you had a complaint would you know who to contact?

• Record Review:

• Is there evidence that the patient verbalized complaints and how the complains were addressed?

• Is there evidence that the patient/caregiver was informed about and contributed to planning his/her care?

• Paper Compliance:

• Request and review a copy of the HHA documentation of complaint investigation and resolution

• Review patient admission packet for instructions for making a complaint

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• Actions:

• Documentation of patient/caregiver participation in POC

• Quote their words

• Document changes in POC have been discussed with pt/caregiver and their response

• Every visit, ask if patient/caregiver is satisfied with care

• Recognition of complaints and appropriate action

• Avoid documenting complaints in visit notes

• Use agency form for complaints

• Complaint/Grievance log

• Complaint investigation process

• Admission packet must have instructions on complaint process for patient/caregiver

Compliance with Federal, State and Local Laws, Disclosure &Ownership Information, & Accepted Professional Standards & Principles (484.12)

• Home Visit:

• Are there instances of staff providing care not supported by laws, regulations, state practice acts, accepted professional standards or HHA policies/procedures (e.g. wound care, prevention of infection, physical assessment, medication review?)

• Record Review:

• Are there examples of care provision not in compliance with laws, regulations, accepted professional standards or agency policies and procedures (e.g., documentation of wound care, wound assessment, or physical assessment?)


• If questions arise during interviews, home visits or record reviews, consider:

• Review agency policies and procedures for the area of interest.

• Identify and review materials that agency provides to staff as clinical procedural resources.

Compliance with Federal, State and Local Laws, Disclosure & Ownership Information, & Accepted Professional Standards & Principles (484.12)

• Actions:

• Ensure staff knows regulations, accepted professional standards and principles

• Includes OSHA, CDC, State practice acts, etc.

• Documentation reflects above

• Policies and procedures

• Documentation of staff education

• Teaching materials

• Resource information

• Training records for specialized procedures

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• Home Visits:

• How do staff members communicate with patient/caregivers and identify the need to communicate with other providers?

• When pertinent clinical findings are noted during a visit (e.g. changes in patient condition, new medication, lab values, updates to the plan of care etc.), how do you follow up or share the information with the appropriate team member?

• Is there evidence that the communication plan was implemented?

• Record Review:

• Is information about patient condition, response to interventions (e.g. medication side effects, responses to wound therapy, and teaching, etc.) and lab values, changes in the plan of care, and discharge planning discussed with or forwarded to the appropriate team members, including home health aide and physician?

• Are case conference, informal conference and phone calls documented?



• If questions arise during interview, home visits or record reviews, consider:

• Review the organizational chart to verify administrator responses

• Review policies regarding coordination of care, communication with team members etc.

• Actions:

• Ensure there is documentation of communication

• With patient/caregiver

• Care coordination between disciplines

• Identification of what needs to be communicated

• Problem area: times of informal communication

• Organizational chart must match verbal responses

• Actual line of authority vs “theory of authority”

• Review policies regarding coordination of care and communication


• Home Visits:

• Did care provider(s) deliver care as ordered and according to accepted standards (e.g., CDC guidelines) and agency policy?

• Did care provider report any untoward or unexpected patient changes timely?

• Is the care being provided as the patient was told it would be?

• Record Reviews:

• Did the HHA begin services as ordered, within the specified time frame, and at the frequency ordered?

• Do plans of care contain all required elements and are they reviewed by physician every 60 days?

• Are plans of care patient-specific (i.e., contain measurable goals and instructions for care that are specific to the individual patient) with stated parameters for measurements where appropriate?

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• Record Review (cont):

• Is there evidence that physician orders obtained after the beginning of each 60-day episode of care are documented and implemented?

• Do clinicians promptly report patient status change, including variance from any parameters stated in the plan of care?

• Is there evidence of patients denied or not offered needed services?

• Review records of hospitalized patients to determine if staffing or scheduling is a problem.




• Review agency policies/procedures regarding obtaining physician orders, new/additional telephone or verbal orders, time frames to start ordered therapies and aide services, reporting patient changes, and specific types of care (e.g. wound care, IV therapy)

• Review contracts of services provided under arrangement

• Actions:

• Ensure staff knows/follows policies regarding infection control (bag technique, cleaning of supplies, hazardous waste disposal, etc.)

• On-site visits periodically with clinicians (before survey)


• Actions (cont):

• Documentation of communication with other staff and physician of changes in patient condition

• Education of patient regarding care provided

• Documentation in clinical record and home folder (as applicable)

• At end of each visit, review care provided with patient

• Clinical record review:

• Care provided

• Orders for care

• Frequency

• 485 (really proofread it!)

• Physician signature/date on 485 and supplemental orders

• Patient specific measurable goals

• Care provided appropriate for patient

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• Actions (cont):

• Clinical record review (cont)

• Parameters present where appropriate?

• Specific to patient

• Process for clinicians to know established parameters

• Ensure patients are offered/receive needed services

• Documentation of patient refusal or previous service provided

• Record review of patients who are hospitalized

• Were services provided and frequency adequate?

• Were there unheeded warning signs?

• Ensure policies/procedures are present for physician orders, time frames for initiation of services, reporting of patient changes, and specific types of care.

• Review contract services

• Most challenging of all employees


• Home Visits:

• Is care provided as ordered?

• Does clinician follow CDC infection control guidelines, state practice act, and accepted nursing standards in providing care?

• Does patient/caregiver know what medications patient is taking and do they match the orders?

• Are patient's needs being met and is patient/caregiver satisfied with HHA services?


• Record Reviews:

• Is there evidence that RN is managing and coordinating each patient’s care:

• Is nursing care provided to each patient as ordered on the plan of care?

• For patients with co-morbidities, is there evidence that inter-related factors are addressed in managing patient’s care (e.g. addressing nutrition and skin care in a diabetic patient with a wound).

• Is there evidence of patient needs that are not addressed in the plan of care of communicated to the physician?

4/14/2016




• If questions arise during interview, home visit or record review, consider:

• Review specific HHA policies and procedures related to areas of interest.

• Actions:

• Following POC is primary reason for citations

• How do clinicians know what POC/orders say?

• Ensure there is ongoing medication review

• Check for non-compliance

• At end of each visit, nurse should ask if patient is satisfied with services.

• Ensure evidence of LVN/LPN reporting to RN for any problems, concerns, &/or need to change POC


• Actions (cont):

• If using paper 485, use as tool for completed interventions, changes in meds, etc.

• Documentation of inter-related factors of co-morbidities

• Notify physician of all concerns and patient needs

• Up to date personnel records with clinicians’ professional experience, competency, training, etc.

• Avoid coercing clinicians to perform tasks they are reluctant to perform

Therapy services (484.32)

• Home Visits:

• Is care provided as ordered?

• Does therapist follow CDC infection control guidelines, laws, regulations HHA policies and procedures and accepted clinical standards in providing care?

• Ask patient/caregiver if needs are being met and if they are satisfied with services

• Record Review:

• Are therapy visits made at the frequency ordered?

• Are assessments & communication with other care providers documented?

• Is therapy provided to each patient as ordered?

• Is there evidence of patient therapy or equipment needs that are not addressed in the plan of care of communicated to the physician?

4/14/2016


Therapy services (484.32)



• Review specific HHA policies and procedures related to areas of interest

• Review personnel records of clinicians that appear to provide care that does not meet laws, regulations, standards & policies.

• Review contracts for service provided under arrangement as needed.

• Actions:

• Same as Skilled Nursing Services

• Evidence of assistants reporting to supervising therapist

• Process for 13th/19th visits and 30-day (at least) functional reassessments (see next slide for 2013 rules)

• Qualified therapists only

• Billing adjustments for non-covered services

• Patient specific, measurable goals

Therapy Reassessment

• Each therapy must reassess at least every 30 days

• Reassessment by qualified therapist

• Must perform ordered therapy service

• Functionally reassess patient

• Compare resulting measurement to prior assessment measurements

• Documentation of effectiveness of therapy or lack thereof

• Note: 30-day clock resets with each reassessment of that discipline


• Home Visits:• How does aide interact with patient/ caregiver?• Did aide provide care as described on written instructions?• Ask patient/caregiver what care the aide provides and whether they

are satisfied with the care.

• Record Reviews:• Were supervisory visits made every two weeks?• Did the RN or therapist ever observe the aide’s provision of care?• Was aide instructed in any clean dressing changes or other

specialized procedures?• Was aide’s care provided according to the written instructions and

the physician orders?• Were written instructions provided to the aide specific to the

patient?

4/14/2016




• If questions arise during interviews, home visits or record review, consider:

• Review agency policies regarding development of aide instructions and aide supervision

• Review aide personnel records

• Review contracts if aide services are provided under arrangement

• Actions:

• Periodic on-site visit with aide present

• Review of aide instructions (care plan) at least every 14 days

• Questioning of patient/caregiver on care provided

• Ask patient/caregiver if satisfied at end of each visit


• Actions (cont):

• Clinical record review of aide supervisory visits

• Frequency per regulations

• If not, examine process for scheduling; write Performance Improvement plan

• Clinical record review of care provided by aide and written instructions

• Patient specific

• RN or qualified therapist (if no skilled nursing services ordered)

• Delegation of simple tasks

• Documentation

• On-site instructions with return demonstration

• Examine policies regarding aide instructions & supervision

• Examine personnel records of aides

• Training, deemed competency, etc.


• Home Visits:

• Are medications in home the same as those listed on plan of care, interim orders and the clinical record notes?

• Is patient status, care provided and medications the same as that documented in the record?

• How does agency staff maintain the confidentiality of protected health information kept in the home?

• Record Review:

• If record seems incomplete, note the date of the latest filing in records and ask about any documentation waiting to be filed.

• Do clinicians consistently document vital signs; insulin injections; blood glucose measurements; wound appearance, location(s) and treatment; and pain location(s), frequency, severity, interventions, & response to interventions?

4/14/2016



• Record Review (cont):

• Are comprehensive assessments complete?

• Are medications on plan of care, medication list (if applicable), and visit notes the same? How are corrections made in clinical record? Is there evidence of different handwriting in the record signed by the same clinician? Were different inks used for the same note?

• Do records of discharged patients contain discharge summaries?

• Do records contain periodic summaries of patient care that were sent to physicians?




• Review HHA policies on documentation, clinicians' time frame for turning in documentation after visits, and time frame for filing documentation. Can the agency provide tracking reports?

• Investigate HHA procedure(s) for making corrections when assessment submitted for data entry of OASIS items is incomplete and check for evidence that changes made to OASIS item responses were submitted to the State.

• Review HHA's OASIS data transmittal records.

• Actions:

• Ensure clinical record is consistent with reality of patient

• Educate on maintaining confidentiality in home, during visits, etc.


• Actions (cont):

• When surveyor arrives in agency, start filing any documents waiting to be filed

• Don’t hand over any patient record until filing is checked and there has been a quick check of chart.


• Completeness of charting (skilled interventions, response to interventions, full assessment and anything specified in orders)

• Review policy on corrections and assess clinicians’ practice

• Surveyors/audit entities suspicious of different ink, lots of late entries, different handwriting

• Discharge summaries for all patients discharged

• 60-day summaries

• OASIS correction process

• OASIS data transmittal processes

• New RAC audit item (semi-automatic)

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• Home Visits:

• Ask the patient/caregiver what medications the patient is currently taking and compare those with the orders, medications in the clinical record.

• Ask patient/caregiver about the course of their episode of home care, whether there have been setbacks or problems and how the HHA has addressed them.

• Ask patient/ caregiver is they are concerned about problems that have not been addressed by HHA staff to their satisfaction.

• Record Reviews:

• If the initial assessment occurred more than 48 hours after the referral was received, was the discrepancy explained (physician ordered, patient request approved by physician)?

• Are comprehensive assessments completed on time and by the appropriate clinician during a home visit at start of care, within 48 hours of (or knowledge of) patient's return home from an inpatient stay, every 60 days (or more frequently), and at discharge?


• Record Reviews (cont):

• If a record indicates that a patient had a "major decline or improvement," was the comprehensive assessment updated?

• Do records show consistency in assessment of patient's status and progress over many visits (e.g., wounds in consistent locations, patient weights seem logical, pain management, presence of Foley catheter, etc.)?



• Review HHA's policies for conducting the initial and comprehensive assessments, drug regimen review, including therapy only cases and when medications are changed after the start of care.


• Paper Compliance (cont)

• Review HHA's policy defining a "major decline or improvement in the patient's health status" that would warrant an update of the comprehensive assessment.

• Review HHA's orientation program for new skilled clinicians, particularly those who are new to home care

• Actions:

• Multiple questions asked about drug regimen review matching meds in home…beware!

• Examine process for comprehensive assessments / SCICs

• Assess patient/caregiver satisfaction

• Timely initiation of care

• Run reports


• Education to clinicians, auditors, data entry

4/14/2016



• Actions:

• Clinical record review for consistent, logical documentation

• Consistent with OASIS documentation?

• Review of policies on comprehensive assessments, drug regimen review, changes in medications, major decline/improvement

• Examine orientation program for nurses new to home health, new to certain skills, etc.

• Should look different than orientation for seasoned home health nurses

Information Analysis“Good gosh, when is she going to leave!” stage

Information Analysis

• Analyzes findings related to each requirement for:• Effect or potential effect on patient care outcomes;• Degree of severity;• Frequency of occurrence;• Impact on delivery of services

• Results of analysis:• Possible extended survey;• Citing of condition-level deficiencies;• Further investigation for related conditions• Based on specific recommendations from SOM

• Action items:• Designate agency person to record all charts audited, patients visited,

surveyor questions, requested documents, interviewed clinicians, etc.

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Exit Conference“Sigh of relief or Let’s rumble” stage

Exit Conference (no surprises)

• Purpose:

• Inform of observations and preliminary findings

• Attendees:

Administrator, clinical managers, and other staff members (as desired)

• Conference content:

• Regulatory requirements not met by the agency

• Allow questions/additional information regarding findings

• Education in response to agency questions

• Clarify areas for possible further deficiencies after surveyor consults with program manager

• Education on form CMS-2567 no later than 10 working days after exit conference

• Instructions and time frame for submission of plan of correction

Formation of Statement of Deficiencies / Violations“worry mixed with relief” stage

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Formation of Statement of Deficiencies / Violations

• What is involved:

• Analysis of:

• Interviews

• Home visits

• Documentation

• Compliance to standards

• Program Manager review

Plan of Correction“are you serious????” stage

Plan of Correction Components

• Determine reason/source of deficiency• Read CoP and interpretative guidelines

• What is the intent and how do you meet it?

• What problem was identified by surveyor?• Where did the failure occur?

• Agency-wide• Individual clinician

• What evidence was listed by surveyor?

• Plan of Correction for each cited deficiency and violation• Even if requesting informal review of deficiencies (IRoD)• Must be typed or legibly written in black ink in second

column of Statement of Deficiencies

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Plan of Correction Components

• PoC (cont)

• Components:

• Responsible person

• Title of person (no proper names)

• Plan for correction

• Includes monitoring for ongoing compliance

• How plan will be implemented

• Examples: training, clinical record review

• How often it will occur

• Consequences of non-compliance by staff

• Don’t make it harder than it needs to be

• When will problem be corrected

• Earliest acceptable date is day after survey completed

• Different severities have different time frames for completion

• Submit within 10 calendar days

Agency Patient-Related Characteristics ReportPreviously called “case-mix report”

Patient-Related Characteristics Report

• Surveyor uses information to get a picture of your agency’s patients

• Demographics

• General health status

• Living arrangements/assistance

• Care management needs

• Status of body systems

• Diagnostic info

• Length of stay

• Reasons for emergent care & hospitalization

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Use of This Report

• Disease management education

• Care path development

• Need for additional policies/procedures/protocols

• Care coordination needs

• Staffing

• OASIS training for accurate answers

Potentially Avoidable Event ReportPreviously called Adverse Event Report

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Potentially Avoidable Event (PAE) Report

• Indicators for potential problems in care

• Measurable change in health status such as # of pressure ulcers

• Change in health status and support available to the patient at discharge (unmet need) such as discharged to community with behavioral problems

• Must be investigated to determine root cause

• Measured from OASIS data at SOC/ROC to DC/Death at home/Transfer to inpatient facility

• Some episodes are excluded from analysis

• Name of patient listed so agency may investigate

PAE

• Surveyor examines 8 of the 12 PAE for the most recent quarter, or longer if necessary to reach 60 patients

• May require record review, home visits, or both

• Tier 1

• Emergent care for injury caused by fall or accident at home

• 1-2 record reviews and 1-2 home visits with record review

• Emergent care for wound infections, deteriorating wound status

• 1-2 record reviews and 1-2 home visits with record review

PAE: Tier 2• Surveyor looks for patient with listed PAE outcomes. If none…

• Surveyor examines Graphical PAE report

• If current PAE item (white bar) is 2x > national reference PAE (black bar), surveyor may focus on those

• PAE items

• Emergent care for improper med admin, med side effects

• Record review plus home visit

• Emergent care for hypo/hyperglycemia

• Record review plus home visit

• Substantial decline in ≥ three activities of daily living

• Record review

• Discharged to the community needing wnd care or med assistance

• Record review

• Discharged to the community needing toileting assistance

• Record review

• Discharged to the community with behavioral problems

• Record review

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PAE

• Now what?

• Know what triggers these items

• Examine/use worksheet to examine each or prioritized PAE

• Clinical record review (visit notes leading up to occurrence)

• Utilize chart audit tool

• Educate clinicians as needed

• OASIS

• Care provision

• Change processes as needed

• Initiate Performance Improvement (PI) Plan as needed

• Implement improvement plan in agency

• Continued review of subsequent PAE reports

• Evaluation of whether PI plan/education is effective

Performance Improvement (PI) Plan

• Statement of problem

• Agency expectations for best practices to occur in the future

• Action strategies

• Methods to monitor and evaluate initiated strategies

• Who will conduct monitoring activities

OBQI Outcome report

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OBQI Outcome Report

• Surveyor selects a maximum of two of ten (sample size of at least 30 eligible cases/last 12 month period):

• Improvement in upper body dressing (≥ 10% lower)

• Improvement in bathing (≥ 10% lower)

• Improvement in transferring (≥ 15% lower)

• Improvement in ambulation/locomotion (≥ 7% lower)

• Improvement in mgmt of oral medications (≥ 10% lower)

• Improvement in dyspnea (≥ 15% lower)

• Improvement in urinary incontinence (≥ 20% lower)

• Acute care hospitalization (≥ 10% higher)

• Improvement in pain interfering with activity (≥ 15% lower)

• Improvement in status of surgical wounds (≥ 10% lower)

• Other

Submission Statistics

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OASIS Submission

• Most recent 6-month period

• Is agency submitting data less often than monthly?

• §484.20: HHAs must, at least monthly, electronically report OASIS data on all applicable patients…”

• RAC focus area with “look-back” of 1-4 years

• Does agency have >20% rejected records?

• If yes to either question, surveyor will look at:

• Policies/procedures for receiving, tracking, data entering and transmitting OASIS data and correcting clinical records

• Does the agency follow their P&P

OASIS Submission (cont)

• Another organization or vendor performing this for the agency?

• Written contract?

• Feedback reports provided to the agency?

• Validation report printout requested for 4-6 records reviewed

• Surveyor assessing if agency can provide reports

• Was at least one assessment per record (e.g., SOC, F/U, Discharge) received by the State?

• High percentage of rejected records?

• Legitimate reason? (large batch submitted twice and all records in second batch were rejected)

• Can agency verify that its software conforms to CMS standards?

OASIS Submission (cont)

• Actions:

• Periodic review of OASIS submission errors

• Must correct any errors and still submit within the 30 day time period

• Ensure policies/procedures in place

• Examine agency processes

• Is there a reason OASIS is not being submitted/rejected?

• Electronic OASIS is “reserved” to a clinician

• Beneficiary information is incorrect

• Submit before the 30th day

• Ensure more than one person knows this process

• Document legitimate reasons for errors

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Error Summary Report


• Surveyor examining most recent 6-month period

• Error 286 (Inconsistent Lock date) (warning)

• Inconsistent M0090/Submission date: The submitted assessment was not submitted within CMS timing guidelines. The submission date is more than 30 days from the M0090 (completion date).

• Should be ≤ 19%

• Error 262 (Inconsistent M0090 date; RFA 4 must be done on an every 60-day cycle) (warning

• Inconsistent M0090 date; RFA 04 (M0090) does not meet cms timing guidelines. RFAs 04 must be done on an every 60-day cycle; (M0090) is no earlier than day 56 and no later than day 60 of that F/U cycle.



• Error 1003 (Inconsistent effective date sequence) (warning)

• Inconsistent effective date sequence: Record does not meet sequence guidelines. Effective date of this record submitted is a date earlier than effective date of the most current record in the system.


• Error 1002 (Inconsistent record sequence) (warning)

• Inconsistent record sequence: the submitted record does not satisfy the sequence guidelines. The submitted (M0100) doe not logically follow the (M0100) previously accepted by the state system.


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• Actions:

• Examine processes for OASIS lock requirement of 30 days

• Assessment must be completed, reviewed, corrected as needed, and data entered and locked within 30 days.

• Used to be 7 days

• Good practice is submission more often than monthly

• Examine process for scheduling recert assessments between day 56-60.

• Surveyor will ask how the agency notifies the clinician of upcoming recerts and how they ensure timely completion

• Examine process for submission of complete patient episodes (SOC/ROC and corresponding Transfer or DC assessments)

• Note: quality episodes are different than PPS episodes

“Not everything that is faced can be changed.

But nothing can be changed until it is faced.”

--James Arthur Baldwin

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Questions???

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FAX: 866.824.5119

Survey Protocols 2016 · G321 EncodingOASIS Data §484.20(a) G170 SkilledNursing Services §484.30...

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Transcript of Survey Protocols 2016 · G321 EncodingOASIS Data §484.20(a) G170 SkilledNursing Services §484.30...