Webinar Recording: Achieving Perpetual Survey Readiness

In this session, Armine Khudanyan, RN, MSN, CPHQ, CEO and Co-Founder of QAPIplus shares five critical actions every home health and hospice organization should take to stay survey ready throughout the year. With CMS intensifying its survey process, including more unannounced visits and greater focus on falls reporting, value-based performance, and quality indicators, agencies can no longer afford to treat compliance as a once-a-year event.

This webinar covers:

• How to improve the way your team collects, documents, and reviews clinical, HR, and administrative data

• What surveyors look for in patient charts, staff records, and home visit documentation

• The role of audits in identifying risk and guiding performance improvement

• How to organize plans, policies, and program data so they are accessible when surveyors arrive

• What staff should know about your QAPI efforts, and how to prepare them to speak to it confidently

Whether you are part of leadership, quality, compliance, or clinical operations, this session offers practical guidance you can apply right away. Watch the full recording to learn how to make survey readiness part of your organization’s daily routine.

WEBINAR TRANSCRIPT

0:04
Thanks everyone for joining us today for our presentation Achieving Perpetual Survey Readiness.

0:10
My name is Joy and I'll be introducing our sponsors and be in the background throughout today's call.

0:16
If you have any questions, please submit those to the Go to Webinar questions box and we will get to as many as we can once the presentation is over.

0:24
Today's webinar is being recorded and a copy of the On Demand version will be on our website after this event.

0:31
For those of you on the live call, you can find a copy of the slides in the handout section of your Go to Webinar menu.

0:38
Our two sponsors today are ACHCU and Quapi Plus.

0:42
ACHCU is the educational division of Accreditation Commission for Healthcare.

0:47
We offer resources designed to help healthcare providers excel in their fields and prepare for accreditation.

0:53
We offer services such as workshops, webinars and workbooks.

0:57
Visit our website achcu.com For more information.

1:03
Our second sponsor today, Quapi Plus is the only quality management software solution purpose built for home health and Hospice organizations that enables you to achieve your highest performance so you can make a real difference for your patients, payers and care providers.

1:18
Joining us for today's presentation is the CEO and Co founder of Kwapi Plus, Amarde Kudian.

1:26
After 20 years helping home health and Hospice organizations stay compliant and improve their quality, Armani found that the old way of managing quality and compliance, including manual data mining papers and binders was not efficient.

1:40
So she created Kwapi Plus.

1:43
You can visit https://quappyplus.com For more information.

1:49
At this time, I'm going to hand things over to Armane Kudian to start the presentation.

1:57
Thank you, Joy, and thank you ACHCU for having us.

2:02
And thank you everyone for attending this webinar.

2:06
Today, we're going to discuss some specific steps organizations can take to achieve perpetual survey preparedness.

2:15
In this webinar, we're going to discuss the five most important things you can do in 2024 to achieve continuous compliance.

2:26
This includes efficient data collection and reporting.

2:30
We will discuss the essentials of proper documentation, both clinical and human resource.

2:37
We will review the impact of data-driven performance improvement on achieving continuous compliance.

2:45
We will explore the importance of centralization of program data and plants.

2:50
And we'll discuss the importance of organizational transparency and training.

2:57
Now, before we get into the main survey preparedness steps, I would like to 1st establish a general framework for the organization to follow when thinking about quality compliance and survey preparedness.

3:14
So why is perpetual survey readiness so critical, especially in 2024?

3:21
Survey preparedness is crucial because it ensures that the organization is meeting all standards set by CMSCMS.

3:30
Surveys are conducted to assess the quality of care provided by agencies, and failing to meet these standards can result in penalties, fines, and even loss of certification.

3:45
By being prepared for a survey, an organization can ensure that they are providing high quality care to their patients, meeting all regulatory requirements, and maintaining their certification, and this can help improve patient outcomes, increase patient satisfaction, and ultimately lead to Better Business performance.

4:08
Additionally, being prepared for survey can help organizations identify where they may need to improve their processes and procedures, leading to ongoing quality improvement.

4:22
So the entire climate of survey preparedness has changed with increased oversight, more aggressive survey processes, increased focus on home health, falls reporting, home health value based purchasing and of course with the introduction of the Hospice special focus program.

4:41
So the idea of continuous survey compliance is important now more than ever and organizations are also feeling the impact of CMS changes in survey process.

4:56
So no more prior notifications of survey, no blackout dates.

5:02
CMS has taken over validation surveys by sending in CMS contracted agents with accrediting organizations to Co conduct the survey which will take over the validation surveys as we were used to being conducted by the state.

5:20
And of course a lot of organizations have felt the impact of state complaint surveys turning into full validation surveys.

5:30
Therefore, all of these recent changes are reasons why organizations should stop thinking of the concept of survey prep right before accreditation surveys and start focusing on the concept of always being survey ready, hence being in a state of continuous compliance.

5:51
So in the next few slides, we will review.

5:55
These slides will be more for your reference.

5:57
I will not be going into any of them in full detail.

6:02
I just included them in this presentation to set the stage for the importance of maintaining quality and establishing robust compliance processes for survey preparedness.

6:17
We have the OIG report of 55% of falls being unreported in home health through omissions on the Oasis reporting.

6:29
This shows that organizations need to have more robust data collection measures to ensure that every fall is captured specialty falls which lead to injury and hospitalizations.

6:46
We also have the home health value Based purchasing, which we know is a payment model that incentivizes home health agencies to improve the quality of care they provide to patients while also reducing costs.

7:01
And this is important in healthcare quality because it has the potential to improve patient outcomes, increase patient satisfaction, and reduce healthcare costs.

7:12
So this model encourages home health agencies to focus on delivering high quality, patient centered care that meets the needs of each individual patient.

7:24
This can lead to better health outcomes and fewer hospital readmissions, which is always a major focus in healthcare quality.

7:33
And the Hospice Special Focus Program is also making an impact on organizations in affected states.

7:40
This program increases focus on identifying full performance based on defined quality indicators that CMS has set in its algorithms.

7:52
It is based on getting condition level findings on the listed 11 Co PS and having substantiated state complaints.

8:03
This model also uses claims data and four indicators in CAPS data to identify full performance in Hospice care.

8:14
I included this slide for your reference to go through each of these measures and ensure your organization is in compliance with all of these Co PS.

8:24
And with this, we have set the stage for the importance of survey preparedness.

8:30
And now I will discuss the general framework for survey prep in a step by step format to help guide the organization towards a successful compliance process.

8:44
So here are some general steps which will give the organization's a little bit of format and structure.

8:52
So step one, it's important to review the current CMS regulations and guidelines specific to home health and Hospice and to be updated with any changes or updates to state, federal, or accrediting body organization regulations.

9:11
It's also important to form a team consisting of key members responsible for survey preparedness.

9:19
It's good to assign roles and responsibilities to these team members, such as having a survey coordinator, the documentation reviewer, and a staff trainer.

9:30
And as we go through the webinar, I will be providing more information about these roles.

9:38
Also, it's important to schedule and conduct internal mock surveys to simulate the CMS survey process and use audit tools to assess compliance with regulations.

9:51
We will do a lot of discussions about audit tools, identify areas of improvement, and develop any action plans to address any deficiencies.

10:04
It's also important to review all policies and procedures related to home health and Hospice services, ensure that policies align with CMS regulations and guidelines, then update or develop new policies as needed to address any gaps or to meet any changes in regulatory mandates.

10:30
It's also important to conduct regular audits for patient records and documentation.

10:37
Verify that documentation is complete, accurate, and meets CMS requirement.

10:43
Address any deficiencies found during audit and provide staff training when necessary and also provide comprehensive training to all staff members on CMS regulations and guidelines.

11:00
Educate staff on the survey process, including what to expect during an actual surveyed and this training should also be provided to field clinicians so all staff members across the board in the organization.

11:15
Also train staff on their roles and responsibilities during the survey, such as interacting with surveyors and providing requested information.

11:25
It is also important to implement and maintain effective infection control practices.

11:32
This will be a major part of survey.

11:35
Regularly assess and monitor infection control measures to ensure compliance with CMS guidelines.

11:43
Provide staff training on infection control protocols and procedures.

11:48
It's very important for staff members to be aware of their own policies and procedures within the organization and this includes hand hygiene practices, back technique, equipment, cleaning and management procedures.

12:05
And also it's important to establish a copy program to monitor and improve quality of care provided.

12:13
Conduct ongoing performance improvement activities to address identified areas for improvement and document and track copy activities to demonstrate compliance during surveys.

12:30
The final steps in the preparation process will include the importance to organize and maintain all necessary documentation and records required for the survey to ensure that records are easily accessible and well organized for surveyors to review.

12:52
Review records for accuracy and completeness prior to the survey and we will discuss how this process should be an ongoing process organizational wide and it's important to communicate and coordinate with CMS, state or accrediting organization surveyors regarding the survey process, logistics set up and to designate a point of contact.

13:18
One person who may be the liaison for the surveyors to get all of the information between the organization and the surveyors.

13:29
I found that this helps the process be a lot smoother.

13:34
Also, cooperate and provide requested information to surveyors in a timely manner.

13:43
Now, after the survey, it's important to review survey findings and recommendations provided by the surveyors, develop and implement corrective action plans to address any identified deficiencies, and monitor and track progress on implementing these corrective action programs.

14:05
And lastly, continuously monitor and maintain compliance with CMS regulations and guidelines.

14:13
Stay updated with any changes or updates to state and federal requirements in the Crediting Organization requirements and conduct internal audits and training to ensure ongoing survey readiness now.

14:28
Also, remember that this procedure should be customized to fit the specific needs and requirements of your organization, as there are different sizes and types of organizations with different services.

14:43
Now these are the 12 steps in the framework for survey preparedness.

14:49
You can use this to organize the rest of the survey preparedness activities, which we will discuss.

14:56
And now we will dive deeper into the content and specific action steps to take to ensure successful survey preparedness.

15:06
Efficient data collection and reporting is the first major step towards successful survey preparedness.

15:15
There is a golden rule.

15:17
I live right?

15:18
So in this webinar, if you learn nothing else, learn this one concept.

15:25
Inspect what you expect.

15:27
This is my golden rule.

15:30
What you expect includes compliance with all CMSCOPS, state regulations, the crediting body standards, your agency specific policies and procedures.

15:44
These are all expectations.

15:48
Now what you inspect, this includes all of your audit tools and data collection tools which will give you a clear picture of your compliance and hence your expectations.

16:01
So if there is an expectation, you have to have a robust tool for its inspection.

16:08
Which brings us to data collection or using data to improve performance.

16:15
Now, the quality of the data collected and how that data is used to improve organizational performance is directly related to the quality of survey preparedness.

16:29
I typically like to divide this data and preparedness activities into 3 distinct categories.

16:36
There is clinical data, human resource data, and administrative data.

16:42
And if you can notice this may this division may also mimic the days of the survey.

16:49
Let's say if you have a three day survey.

16:51
In those three days surveyors will review clinical data, human resource data, and administrative data.

16:58
So this is a good way to divide your the giant task of survey preparedness into manageable categories.

17:09
Now.

17:09
Clinical data includes all clinical documentation processes, clinical record reviews, clinical KPIs and performance.

17:18
Human resource data includes process of employee hiring, credentials verification, primary source verification, background checking, proper orientation, and of course, the most important effective competency assessment of staff.

17:39
Now administrative data includes programs such as the copy program, infection control, Emergency Management, medication management, and for Hospice organizations, the volunteer program and bereavement program.

17:57
Hence, when we think about data, we can divide it into these three categories.

18:03
In your organization, you can have a team lead for each category reporting to 1 main survey prep coordinator.

18:11
Or if you're a small organization, the main survey lead will prepare all three categories of data.

18:18
Now, data sources can be internal and external.

18:22
When we talk about data, there are two main sources we typically use in home health and Hospice, which includes incident report data and audit data.

18:33
Now incident reports include falls, infections, patient complaints, adverse events, medication errors, hospitalizations, and audit data is the outcome of all of the audits we do for clinical records and for HR records.

18:55
Now streamlining Streamlining data collection and reporting is essential because collecting data means nothing if the organization does not have an efficient process for improvement.

19:09
This process includes who is collecting the data?

19:13
How is this data being collected?

19:15
Is the data collection process efficient?

19:19
Is the data collected being used to drive decision making?

19:24
Often times we see organizations collecting a lot of data but failing to have a process of efficiently aggregating and analyzing the data to achieve process improvement.

19:37
Organizations may fail in using data to drive their performance improvement projects and know how to effectively monitor outcomes quarter after quarter.

19:49
Therefore, to become survey ready ready at all times, it's important to find opportunities to streamline and standardize these processes with using technology.

20:01
It's a great way to automate processes to enable real time data analytics so that the organization can always be survey ready.

20:12
Here is an example of how we help organizations automate data aggregation, calculation and reporting which takes the busy work out of compliance and fees up essential clinical resources to spend more time on the improvement processes rather than that pre work of collection and aggregation.

20:34
So I have used my years and years of survey experience to build the survey preparedness logic into the single software to help organizations maintain state of continuous compliance.

20:47
So in summary, identify the data to be collected, aggregate the data efficiently and effectively and use it to drive your performance and your survey preparedness.

21:02
And with that, he will transition into proper documentation, which is a major step for survey preparedness and continuous compliance.

21:14
So of course we always know document, document, document and then document some more there need.

21:21
So the organization should create a process for clinical documentation compliance.

21:28
The strategy that I have developed that I have used over the years to help organizations drastically improve their process for clinical documentation improvement, I teach organizations to divide clinical documentation review into two distinct categories.

21:48
As you noticed, I divide everything into categories, which makes it manageable.

21:54
So there is compliance and then there is quality compliance can be audited by a document specialist who may not necessarily have a clinical background.

22:05
This is what I call a technical QA of a chart.

22:09
It basically answers questions such as does it have all the parts it needs?

22:14
It's a technical checklist, our consent form signed and complete.

22:20
Is there a comprehensive assessment?

22:22
Is there a plan of care?

22:24
Are home visits done?

22:26
Arnold submitted our physician order signed.

22:30
This is a technical review of a clinical record.

22:35
Now when we get to quality, quality is assessed by a clinical reviewer.

22:41
Does the care provided follow physician orders?

22:45
Does the plan of care capture all necessary interventions?

22:50
Is it patient specific?

22:51
Are goals measurable with time frames?

22:54
All of these quality pieces that goes into clinical documentation.

22:59
The idea here is that there cannot be quality without compliance.

23:06
If a clinical record is not compliant, it cannot have quality.

23:12
Therefore, I understand it may not be feasible to complete a quality audit on all records, but it is possible to complete a technical audit record to ensure that there is compliance.

23:29
So with that, in these next three slides that I know I have jam packed with information which is really for your review.

23:38
I won't go through each line item 1 by 1, but I have included some essentials of clinical documentation and human resource compliance for both home health and Hospice.

23:53
These are for your reference in our examples of some major areas of focus when it comes to clinical documentation.

24:01
I have chosen these KPIs to share with you because these are the major documentation risks which may cause poor survey outcomes and we'll give you a mini guide of where to start to achieve compliance.

24:17
So in Hospice the list may include having a proper election of benefit, having proper consent forms, patient handbook, having Hospice eligibility documented, ensuring core services are provided through comprehensive assessments, care planning, IDT documentation, patient family education, discharge planning and summary post death assessments.

24:49
So these are the essentials of clinical documentation in Hospice.

24:56
In home health, these are the major KP is which tend to get standard or condition level findings during surveys.

25:03
Again, this is a mini guide for documentation compliance in home health.

25:08
This is all I could fit on the slides.

25:10
So I'm sure there's a lot more, but in home health, we focus on homebound status, timely initiation of care, ensuring that Oasis documentation is complete, making sure the plan of care captures all required data, medication reconciliation process, discharge planning.

25:34
So all of these parts are essential for clinical documentation in home health.

25:42
Now here are some essentials of human resource record reviews.

25:48
We can focus on ensuring that the application is complete, that the employee has the education and background requirements for their role as outlined in their job description.

26:03
Making sure that primary source verification is completed for licensed clinicians both at the time of hire and before a license expires.

26:14
Making sure all credentials are current and up to date, new hire orientation, including all required content, and making sure that proper competency assessments are completed and ensuring that appropriate disciplines are completing the competency assessment.

26:35
For example, an RN cannot determine the competency of a social worker since they are not with the same discipline and do not have the same training.

26:46
However, an RN can complete a performance evaluation for a social worker.

26:52
So it's very important.

26:54
I bring this example because this confuses a lot of a lot of organization and it gets the most findings during a survey.

27:04
So I want to point out that little distinction when it comes to survey preparedness in human resources.

27:14
Now, all of the KPIs we just discussed can be turned into audit tools, and these tools can be used to monitor compliance.

27:24
Auditing follows organization to It allows an organization to identify their own compliance risks.

27:33
So the agency should set goals for compliance, then conduct audit to see if they meet their compliance goals.

27:41
For any KPI which does not meet the goal, an actionable performance improvement project should be created.

27:50
So here's a sample process an organization may go through.

27:55
Clinical and HR audits should be done monthly.

27:59
The data should be aggregated and presented to copy committee quarterly who will then review the results and come up with performance improvement measures to correct any areas of non compliance or areas where the agency set goals are not met.

28:18
So we refer to this process as data-driven decision making and data-driven performance improvement.

28:27
This cycle will continue until the agency reaches their goals and compliance is achieved, which leads us directly to data-driven performance improvement.

28:46
So use your data to prioritize improvement by the size of the impact.

28:54
Make sure your organization is focused on the right projects which have the biggest impact on patients on performance and OnStar ratings.

29:06
Make sure to incorporate data from all sources, including patients, feedback and satisfaction.

29:14
Have a proactive process of improvement based on data-driven needs to prevent the organization from a state of what I call reactive performance improvement.

29:28
A reactive performance improvement process means the organization waits until there is a problem, a complaint, or a poor survey outcome before creating a performance improvement project.

29:42
This is not a good process.

29:44
A good process is identifying compliance risks and mitigating them before a problem occurs.

29:53
Part of this process is making sure data is easily accessible and that this data is used to develop training materials for staff in order to improve performance and increase staff buy in, in performance improvement practices.

30:14
And that brings us to our 4th step in data in survey preparedness, which is very which is a very important concept of centralization of program data and plans.

30:32
Now what do we mean by this?

30:35
It's very important for an organization to ensure that all staff members, including bedside staff, have access to quality improvement metrics, initiatives, trends, and expectations.

30:52
Many organizations and surveyors can relate to the fact that often your clinicians are not aware of the administrative performance improvement initiatives of the organization, yet their performance and documentation directly impacts it.

31:10
So we need to find ways to close this gap.

31:14
For this reason, it has been my mission at Copy Plus to give access to all clinicians, to give them access to current quality measures and performance improvement projects being worked on so that they feel directly involved and engaged with this process in order to close this gap between administrative processes and field nurses.

31:42
Therefore, it's important to make sure that data is accessible and available to all stakeholders in the organization, therefore standardized as much as possible and create easily accessible survey preparation checklist for your team.

32:05
It's also a great practice to have a single survey document management center where staff members can have access to survey readiness documents should the organization be faced with a surprise, unexpected survey.

32:22
So have one place, wherever this place may be to manage all of these survey documents.

32:30
So in the case where a surveyor walks in from any organization, state, federal operating body that staff members can easily have access to these documents.

32:44
So there is no panic or struggle during this time.

32:50
Hence, having accessible quality data leads to our final step of survey preparedness, which is the concept of transparency and training.

33:06
Now, to be ready for survey, all staff members need training, audit, staff competency and knowledge of the functions of the copy committee to ensure that field staff are knowledgeable about these practices.

33:27
Some questions to discuss are, can staff members speak to a surveyor about their copy process, about the poppy plants, current projects?

33:40
Can they speak to this?

33:42
Are they aware of their Emergency Management plans, their processes?

33:48
How about their responsibilities during an emergency?

33:52
Are staff members trained in this?

33:54
Can they clearly discuss these with a surveyor?

33:59
That's important part of preparedness.

34:03
Have staff members participated in testing and stressing the Emergency Management plan?

34:09
Can they speak to a surveyor about that?

34:12
For example, are they aware of their backup communication practices or how do they get in touch with staff members or with their patients doing an emergency?

34:26
Have they completed patient specific emergency forms and evacuation plans and is this information shared with patients, families and organization members?

34:39
So it's very important that they're trained in and adhere to agency policies, procedures in all of these practices.

34:49
And this also includes practices in infection control, medication management, process of medication reconciliation, hand hygiene, equipment management.

35:05
So it's important to provide organizational transparency to clinicians, share incident rates and trends with them, show them the impact of their hard work and their commitment, distribute outcomes of tips so that they can know that the agency cares about these outcomes and their performance.

35:26
This is a major step to cause behavioral change in clinicians for adopting best practice and evidence based practice into their routine patient care.

35:38
So increase training and education on compliance and quality and make sure that all staff members have access to frequently used policies and procedures so they may know if if they are wondering about something or if they're asked a question from a surveyor.

35:59
At the very least they can say I know where my policies and procedures are and I can go in and review them at any time.

36:10
So the best way to accomplish the task of staff assessment and education is through conducting supervisory visits.

36:22
Really go out with staff and observe them.

36:26
Don't let the surveyor be the first person to observe field staff.

36:31
Go out with staff members often and practice conducting a home visit with a supervisor.

36:38
Observing this will give the staff member the experience of doing their work with someone watching them.

36:45
This is when a lot of those breaks in practice occurs, when clinicians get nervous and are not used to being observed.

36:56
But the more this is practiced, the more it becomes second nature.

37:02
So have a standardized formal supervisory audit tool to check compliance and identify any areas of risk.

37:12
Now once the risk is identified, then work towards a corrective action.

37:20
For example, let's say one of your home visit requirements is to conduct the comprehensive medication reconciliation at every nursing visit.

37:33
Let's say this is a requirement.

37:34
This is one of your expectations that as a supervisor, when you go to supervisor clinician in the field, among all of the required things that they do, completing a medication reconciliation at that visit is a requirement.

37:52
So then out of 10 joint visits, let's say medication reconciliation was done only 6 times.

38:02
This means that the agency is only 60% compliant with this KPI.

38:08
So it's important to quantify and to have ways to numerically measure these compliance rates so that the organization is aware of where they sit within the compliance spectrum.

38:26
So once you know that you're only 60% compliant with this KPI, the organization can do a root cause analysis of why the other four times the Med rec was missed.

38:41
Did the nurse forget to check the medications?

38:44
Were the medications not accessible in the home at the time of the visit?

38:49
Did the patient refused to show the medications to the clinician?

38:54
Whatever the circumstance is, it's important to document all of those reasons and come up with ways to mitigate those reasons and provide training to staff members regarding what actions to take should they come across these reasons again in the future.

39:16
So this is this is more specific training that gets to the root of the issue that may then in the next quarter increased performance and compliance to that specific KPI.

39:32
So let's say you find out the reasons, the four reasons why those 4 visits had missed a Med rec and you create a performance improvement project.

39:43
Now you use those four reasons of why it had failed and you create actionable interventions for clinicians to take in future visits and you provide this training, you disseminate the information and you make sure that all clinicians have been notified regarding this expectation of doing medication reconciliation at every nursing visit.

40:12
Now, next quarter you do 10 more supervisory visits and recalculate your compliance.

40:18
If this if this quarter Med rec is done during eight home visits, this means that in one quarter you increase your compliance rate of medication reconciliation at every nursing visit from 60% to 80%.

40:36
This is the process of using audit tools, using data to drive your improvement and you keep this cycle going over and over again until you reach your compliance.

40:53
Now in conclusion, to be survey ready at all times make sure to have efficient data collection tools and processes.

41:06
Have a clear expectations for clinical and HR documentation practices.

41:14
Build data-driven performance improvement project which can be quantifiable.

41:22
Centralized your program data and plans to allow staff easy access to quality metrics, trends and outcomes.

41:33
And finally, increase organizational transparency and provide staff training through direct observation and quantifiable performance metrics.

41:49
I want to take this opportunity to thank you all for joining me on this webinar and thank you to ACHCU for this great opportunity.

42:00
Before I end, I do want to leave you with this one final thought.

42:06
Each type of organization has their own specific needs and challenges which directly effects compliance and survey preparedness.

42:19
Single locations, right?

42:21
Small organizations may have the challenge of not having an in house compliance experts to guide this survey process.

42:31
This is one challenge that small organizations may face.

42:35
Medium sized organizations may have the clinical expert with experience in compliance.

42:42
However, due to staffing shortages, this individual may be constantly pulled to direct patient care responsibilities instead of survey preparedness and compliance responsibilities.

42:55
So we see this often with medium sized organizations where they have the skill set, the knowledge base.

43:03
However, this individual is always responding to direct patient care needs.

43:11
Now, large multi state, multi location organizations face the challenge of centralizing all of their programs and having standard tools for all of their locations to use this.

43:30
This may keep them from being able to compare one location to the other location to have some insight as a organizational wide or as a corporate level what their compliance rates are.

43:46
They may be able to see individual location compliance, but it's hard to roll up as an organization because maybe it's hard to standardize the data collection tools and kind of this gives them that opportunity to compare apples to apples and oranges to oranges.

44:04
But regardless of which type of organization you fit into, it's challenging for everyone.

44:12
It's a continuous process.

44:14
It's a learning experience.

44:17
Most of the, any deficiencies, any poor survey outcomes that an organization may have, it's best to use it as a, as a tool for improvement and as A and as a learning process.

44:35
So regardless of which type of organization your agency fits into, you can develop strategies for successful survey preparedness and for continuous compliance.

44:49
Thank you.

44:55
Thank you.

44:57
Yes, I was just going to say at this time we do have some questions that I can go ahead and share with you.

45:03
All right.

45:07
Our first question is what is the expectation to present incident logs to Surveyor if the data is collected and stored in a patient safety work product privilege regulated database and thus is locked and not viewable, just a minimal print export?

45:25
Or verbal reading of information stored, that's a great question.

45:31
So typically surveyors look at the trends of incident report data.

45:39
They look at the trends quarter over quarter and what interventions were done, what process improvements were done for the trends.

45:50
It's rare that a surveyor may want to look at a specific incident report unless they're doing some sort of like a, that's call it like a tracer activity, right?

46:03
So let's say if a surveyor is reviewing A clinical record and a record has a patient transferred to the hospital with a fall with major injury, the surveyor may want to see if this was captured in the organization's copy program.

46:25
This is a way for them to check and test to see how robust the data collection process is of the program.

46:33
So they may ask to see that incident report for that purpose or if there, if there are reading documentation or during a home visit, they identify a medication error or anything like that is identified, they may ask for that specific incident report.

46:55
So it's not typical that a surveyor will go in and ask for every single incident report.

47:03
They will look more at the trends unless they're trying to dive deeper into an incident that's related more to clinical documentation or home visits.

47:17
Great, thank you.

47:18
Next question, can you comment on how you define the home health delayed start of care notification to MD?

47:27
Must be specific and not include ranges if a notification that states 126 or 127 on the order notification is valid.

47:38
So when it comes to timely initiation of care, the two important concepts is 1st to see if there is a specified date for that start of care ordered by the physician.

47:53
If there is no specified date, then the initiation of care typically should happen within 48 hours from the referral.

48:05
If this care is delayed, it should be the physician should be notified via physician order.

48:14
Like typically ask organizations for this instead of this being like a calm note for it to be an actual order signed by the physician letting the organization know that it is OK with the physician that this service has started at, you know, on day three.

48:34
This, this is very patient specific and it depends on the needs of the patient.

48:39
For example, if the patient requires any kind of medication or any kind of high risk medication treatment or family education, it's very, very important to make sure that that care is provided timely.

48:58
Or for example, if a patient is coming home post hospitalization or post surgery, if the the clinician does not go in within let's say 24 hours and do a Med rec and remove let's say the anticoagulant and teach the patient, OK, you're back from surgery.

49:15
You do not take your anticoagulant and the patient has an episode of bleeding that may have a negative impact on the patient.

49:24
So most often these the late start of cares don't cause patient harm, but they can.

49:33
So I think a physician should be notified and have documented approval from the physician of delaying the start of care.

49:45
Thank you.

49:45
Next question is the 90 day eval requirement in ACHC standard requirement, the 90 day eval OH for performance evaluation for HR.

50:02
So yes, the 90 day performance evaluation is required and that is basically your first 90 days of hiring an employee where you can, where you can give feedback to of their performance should the employee not be a good fit for the organization.

50:24
This is basically your first 90 days of that.

50:28
Where after the 90 days then the employee becomes part of your organization.

50:36
And so the performance evaluation should be done at 90 days and then it should be done annually thereafter after that date of hire.

50:49
And can you just clarify that this is also needed for all positions or specific positions?

51:02
So this would be required for all positions.

51:08
It's just for some positions, it's more important than other positions.

51:14
For example, for clinical staff providing care to patients in the field, this would be very important, but it is important for all, all staff members.

51:26
Making sure that you have documented 90 day performance evaluation.

51:31
Typically when we do survey prep or we do survey education, we do train for the 90 day eval to be completed for all employees.

51:44
Great, thank you.

51:45
And another question as part of this follow up, what fall, sorry, do medical directors need competencies?

51:54
We get that question a lot and honestly I have found that to be surveyor specific.

52:02
Some surveyors will check and make sure there's a full competency assessment and you know full process done on the medical directors.

52:13
We train to have that process because all, especially Hospice organizations tend to have a a backup physician in case their medical director is not able to function for any reason.

52:28
So if there is any medical director designee, it is important for them to do that evaluation on each other just to make sure that that competency checklist has gone through.

52:42
It's just best practice because especially in Hospice care, I think it's more important than Hospice care that all clinicians as part of the IDT have had that due diligence of competency assessment.

53:00
OK, next question.

53:02
Many Pips could be instituted with self audits and there is a limit for what staffing is able to be completed.

53:09
How do you view awareness of need for APIP on an item but have not engaged due to limitations to complete the work until other Pips are completed?

53:20
Would that be valid and not be cited?

53:25
So you can think of TI PS, there can be a lot of opportunities for TI PS.

53:34
So Pi PS can be, there can be opportunities from clinical, from operational, from financial budgeting, from business practices.

53:46
So when you think of performance improvement projects, the name of the game there is prioritization.

53:54
So when you're doing all of your audits and you're looking at the data during that copy committee meeting, the team, this is what the team would discuss.

54:08
And performance improvement projects should be prioritized by their effect on the patient first.

54:17
Anything that affects patient safety, patient care, patient outcomes should be prioritized and improved first.

54:25
Then you can go into organizational, operational, then business and financial.

54:32
So you would line up all of the areas of performance improvement opportunities and prioritize it based on its impact on direct patient care because all of our goal here is to improve patient care and deliver high quality, safe patient care.

54:57
Thank you.

54:57
Next question, please clarify the health records for employees.

55:03
We do not collect COVID vaccinations since the end of the pandemic.

55:07
Is it required?

55:09
We do not do health clearances or require flu vaccinations.

55:13
Only if state required.

55:15
Does ACHC require this across all home health and Hospice companies?

55:22
So ACHC stopped requiring this after the pandemic at CMS and most states made it.

55:31
The made those requirements to be specific to the organization.

55:37
For example, the organization can decide whether they want to make sure that all of their staff members have COVID-19 vaccinations and flu vaccinations and whether they will have direct patient care assignments or they won't due to their vaccination status.

55:57
So a lot of these processes transitioned into agency policy and procedure.

56:04
So if the agency requires it, then it's required.

56:07
This is why policies and procedures are checked that This is why surveyors will ask for your policies and procedures to see if you follow your own policies and procedures.

56:18
So at this time, ACHC specifically has stopped that mandate, right when CMS stopped the mandate.

56:26
So now if the organizational policies procedures ask for it, then they require it.

56:35
If not, then they don't.

56:37
So this is up to the organization and your state laws.

56:44
Thank you.

56:45
Are you saying that CMS will survey us with our accreditor every time?

56:50
No.

56:52
So the CMS surveys with the accrediting organization, that is a new process that took over the validation surveys which were being done by the state Department of Health.

57:05
So in the past after accrediting surveys, there was a random sample of organizations that received a state validation survey right after their maybe like a month after their accreditation survey.

57:20
And this was CM s s way of validating the survey conducted by the accrediting organization.

57:28
So this process is being transitioned out of the state's jurisdiction to CMS.

57:37
So instead CMS will be sending CMS agent with the crediting organization.

57:45
And it is my understanding that this is also a surprise to the accrediting organization.

57:50
When this happens, I don't think the AOS know which surveys will be accompanied with the CMS person.

57:59
So this will be that random sample of what is it like 5% of organizations that may receive a validation survey that they will have ACMS agent along with their crediting organization surveyor.

58:16
So no, you will not see this every survey.

58:18
This is not routine.

58:19
This is just for validation.

58:21
But do keep in mind that CMS made the mandate for state complaint surveys to turn into full validation surveys.

58:33
So now every time there's a complaint survey in the past, the State Department would come in, they would investigate the complaint and you know, they may check a few other charts around the complaint and that was it.

58:48
But today it's turning into a full validation 3 day multi surveyor survey process where there is a full validation survey with some real consequences towards it regardless of when the accrediting organization survey was or will be.

59:10
Great, thank you.

59:12
Incompetency skills and RN cannot evaluate the performance of a social worker and a small company with one social worker.

59:19
What's your suggestion?

59:22
So a registered nurse?

59:25
A registered nurse?

59:26
We face this many times and I have asked multiple surveyors and the consensus has been this that if that the social worker conducting the competency of the social worker employed by the organization does not need to be directly employed by the organization.

59:46
So if there is another social worker, that social worker may sign off on the competency skill set of the social worker without being directly employed by the organization.

1:00:01
But still a registered nurse can't do the competency of the social worker.

1:00:08
Thank you.

1:00:09
What fall requirements are there for Hospice agencies?

1:00:15
What fall requirements?

1:00:20
Correct.

1:00:24
I think you're referring to if a patient falls.

1:00:28
So all patient falls, all patient falls should be documented whether there is injury or not.

1:00:36
And I also urge organizations to document near falls because it is part of that proactive performance improvement where in the future they can prevent, they can prevent actual fall with injury.

1:00:52
So for Hospice organizations, as patients are, you know, diminishing in their functional ability, if a Hospice is not able to prevent all falls, it can have a working group that may prevent injury caused by falls.

1:01:15
In falls prevention trainings, we talk about almost like teaching patients how to fall or what not to do during the fall.

1:01:23
As in if you're falling, fall, don't, you know, try to grab on to something that you're going to pull and and it falls on top of you because you're trying to prevent that fall.

1:01:34
So again, being proactive is the most important way of preventing falls.

1:01:40
And yes, the Hospice should capture all of the falls and document performance improvement projects.

1:01:50
Risk based.

1:01:51
The best thing a Hospice can do for falls documentation is assessing the patient's individualized risk for fall.

1:02:00
So and teaching them based on that individual risk and making sure to have a full fall prevention program and to prevent every fall as possible.

1:02:12
Because it's such a shame to have a terminal illness and then have a fatal event that is not tied to your terminal illness.

1:02:22
And that goes with all high risk processes, hypoglycemic events, falls, all of these high risk events that patients may encounter in Hospice.

1:02:37
Thank you.

1:02:38
The next question, what are validation surveys?

1:02:42
Validation surveys are surveys after an accrediting organization.

1:02:48
It's basically a repeat of your survey.

1:02:51
Let's say you, let's say you're an accredited organization, you had your first triannual survey come in and let's say ACHC comes, they do your survey and they leave you do your plan of Corrections.

1:03:04
Everything is accepted one month later.

1:03:08
Now.

1:03:08
This is what used to happen as a validation survey.

1:03:10
One month later, the state department would come in.

1:03:14
It's basically a RE survey to assess if the accrediting organization was able to identify all of the risks associated with the organization.

1:03:30
So if let's say an organization went through a survey with 0 findings or with one finding Prime and of Health would follow and do their own assessment to make sure kind of how valid was the accrediting organization's process.

1:03:46
And I think this is a process CMS put into place just to make sure that all of the accrediting organizations had robust survey processes and we're doing a good job with risk identification.

1:04:02
So it was like a mini repeat survey.

1:04:07
Great.

1:04:07
OK.

1:04:07
And do MSW need competency evaluations at higher?

1:04:12
Yes, MSWS, spiritual counselors, chaplains, they need competency evaluations of their skills because they are part of that IDT.

1:04:25
They do perform, they do provide care to the patients, they're part of core services.

1:04:31
So it's very important for another spiritual counselor, another social worker to check the competency to make sure that they are providing safe care and that they know simply they, they know how to work with families, they know their resources, they know how to discuss end of life care.

1:04:56
So all of these, they know bereavement.

1:05:00
So all of these competencies need to be assessed with a like discipline clinician.

1:05:08
Absolutely.

1:05:11
Thank you.

1:05:11
Are there specific competencies that a surveyor will look, for example for a nurse?

1:05:17
Yes, they will look.

1:05:20
For now, the competencies a surveyor would look for directly has to do with the services provided for the organization.

1:05:29
For example, if a home Health Organization is providing IV care, wound care, a surveyor would go in and directly look at the competency to see was this nurse's competency checked with IV administration, with let's say PICC line dressing changes, wound care and for all for weight testing as part of CLIA, they may look at competencies for blood glucose management, for glucometer management.

1:06:05
So there are very specific skills, infection control, kind of the head to toe assessment.

1:06:13
There are specific skills that the surveyor will go in and look at for the clinical competencies.

1:06:19
And so any service that the organization is providing, they should go back and check to see if that competency was assessed.

1:06:28
For example, if your state allows the home health or Hospice aid to apply, let's say, medicated creams to intact skin, let's say they're, you know, after they're going to apply cream, let's say to someone's sacral area and there's no wound.

1:06:46
If let's say state allows that then a surveyor may go into the competency and see if that type of medication administration competency was done for the CHAJ.

1:06:58
So any, so you can tie it to that, any practice, any service you're providing to your patients, make sure that that competency is well documented in your in your HR record.

1:07:14
Well, great, thank you.

1:07:16
We do still have some additional questions, but unfortunately, our time here is up and what we will be doing is we will be answering those additional questions through e-mail.

1:07:28
So we do have the names of those who have asked these questions and we will be sharing those with Armani for her to respond directly to you.

1:07:37
Again, I would like to like to thank our presenter, Armani Kudiyan, and thanks everyone for joining us today for our web webinar, Achieving Perpetual Survey Readiness.

1:07:48
Please be sure to visit thequapiplus.com website to find out more about RNA services and achcu.com where you'll find access to today's recording along with other past webinars and other tools that we offer.

1:08:03
And thank you everyone for participating.

1:08:05
We hope that you have a wonderful rest of your day.

1:08:09
Thank you.

1:08:09
Have a good day.

1:08:10
Wonderful and thank you everyone.

1:08:13
Thank you, Joyce.

1:08:14
Thank you.