1. Top Ten Problems Found on Survey MedTrade Spring Wednesday, April 25, 2007 Mary Ellen Conway, President Capital Healthcare Group

2. Top Ten Problems On Survey Learning Objectives: What is the format of a survey? How can you prepare? What is reality and what is a myth? The top 10 problems found and how you can avoid them

3. Where Do We Begin? What is the typical format of the survey? –Now all are unannounced –Formats JCAHO Tracer Methodology Review of Patient Lists, Personnel Lists, Patients Scheduled for Visits

4. Two-Day Survey Day One Entrance Conference Interview of Leadership Review of Survey Schedule Review of Patient Census Selection of Patients to Visit (Close to the Office) Review of Patient Charts (Include those being visiting) Selection of Employee Charts (or Tracers to Determine) Patient Visits and/or Chart Review End of Day Wrap up and Plan for Tomorrow May take Policy/Procedure Manuals, PI Program info to review overnight

5. More on a Two-Day Survey Day Two Review of Day One or items reviewed overnight Continue Patient Chart, Personnel Chart review Continue Visits, Staff Meetings Telephone Interviews Can Include Referral Sources, Discharged Patients Review PI program Review minutes of Board Meetings, planning sessions, staff meetings Exit Conference Required to mention all recommendations/concerns

6. Before We Begin Ensure that you have worked through your accreditor’s standards –Make sure your policies and procedures are aligned with the accreditation company’s standards –You have completed all requirements

7. CMS Final Quality Standards Were released on 8-14-06 !!! 14 pages—as compared to 104 in September 2005 Found on the CMS website at: (http://www.) cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_Standards.asp Compliance with these standards will be enforced through the accreditation provider you select

8. #10 Psychotic Surveyors Myth or Reality?

9. Is it Myth or Reality? Fact: –You are the accreditor’s customer –You have ways to appeal –You need to be prepared!

10. In Preparation, Create Your Checklist Develop your own or purchase one Check to make sure you have everything you need on your list –Review your standards/guidelines –Make sure each aspect of your services and ALL types of services you provide are addressed (retail, delivery, on-line?)

11. Creating Your Checklist Warehouse/layout Educational Calendar Staff and Patient Interviews Infection Control and Surveillance Performance Improvement/QI Personnel Files Patient Records HIPAA Home Visits

12. Keep in mind any other compliance that might be assessed, such as HIPAA Review your entire operation for HIPAA compliance especially : –Customer areas –Staff areas –Security of files, billing, patient records, delivery logs, items patients sign –Shredding? –Process for sending patient information and receiving referrals and orders Example: What’s at your fax machine? Cover Sheet Text?

13. #9 Everyone Doesn’t Need to Know This Stuff Myth or Reality?

14. P.I./Q.I Programs Performance or Quality Improvement Usually the one area that organizations have not had in place prior to the pursuit of accreditation Can be done internally without outside assistance---but may require benchmarking Focuses on item/area that can be monitored and improved (Customer Satisfaction)

15. P.I./Q.I Programs Are Written Show involvement of staff (as many as appropriate) Program is presented, approved and reported on quarterly Generally need to show at least 3 months of data when you submit your application. Data should be collected, analyzed and acted upon (all of this is written in the PI Report)

16. Patient Satisfaction Benchmarks S Office Mean D Office Mean V Office Mean Overall Mean Overall Mean Last Quarter All Offices (including B) National Mean Region 3 Mean Overall Mean Agency 95.287.688.690.4688.790.091.1 Nurses Taught Self Care 95.791.395.994.392.391.892.8 Family Involved in Planning 88.889.391.789.9385.387.287.8 Arranging Home Health 89.984.883.085.988.188.989.9 Second Quarter Washington, Division FY 2006

17. Overall Mean Agency

18. Performance Management 1.Beneficiary satisfaction surveys 2.Patient complaint log 3.After hours (on call) log to prove timeliness of response to questions, problems and concerns 4.Log that documents frequency of billing and/or coding errors 5.Log documenting adverse events (as defined by your P & P manual) Most accrediting organizations require at least three months of surveys collected and summarized with plans for improvement or you will have to provide written follow-up and possible a re-visit

19. Is it Myth or Reality? Fact: –Everyone needs to know what’s going on –You can not do things in a vacuum –Everyone needs to be prepared!

20. #8 No Ride Alongs? Bad Idea– Myth!

21. Reality Fact: –There is no insurance issue –If questions are not asked during the ride, they will be asked at other times –Practice interviews, safety issues –Examples

22. #7 Inventory Management What is Required?

23. Final Supplier Quality Standards 2 Sections First Section: Business Services –Administration –Financial Management –Human Resource Management –Consumer Services –Performance Management –Product Safety –Information Management

24. CMS Final Quality Standards Financial Management 1. Implement financial management practices that ensure accurate accounting and billing. 2. Accurate, complete and current financial records 3. Cash or accrual based accounting 4. Link equipment to client 5. Manage revenues and expenses on an ongoing basis: Reconcile charges with invoices, receipts and deposits Operating budget Mechanism to track actual revenues and expenses

25. CMS Final Quality Standards Product Safety Equipment management program that promotes the safe use of equipment and minimizes safety risks and hazards including: 1.Plan for identifying, monitoring and reporting failures, repair and preventive maintenance 2.Investigate any accident or injury (within 72 hours or 24 hours if results in hospitalization or death) 3.Contingency plan for response to emergencies and disasters

26. Requirements Must Comply With: –CMS Final Quality Standards –Your Accreditor’s Requirements

27. #6 Competency Program What is Required?

28. CMS Final Quality Standards Human Resource Management Implement policies on: Specific qualifications Training Experience Continuing education requirements Technical personnel: Competent Licensed, certified or registered (and current copies on file)

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

30. Is it Myth or Reality? Fact: –Competency Program must have been completed before survey –Can be by job description or by item, or both –Licensed staff have to review each other

31. #5 “Red Tape” on the Floor Myth or Reality?

32. Is it Myth or Reality? It’s an Urban Legend! –You are held accountable for following your own Policies and Procedures

33. #4 Preventive Maintenance What Do I Need to Have Available?

34. Reality Fact: –You need to be able to explain your program for Preventive Maintenance on appropriate items How to identify items in the field that need it How to show that it’s been performed appropriately and timely

35. # 3 Policies and Procedures A “MUST HAVE” in order to become accredited

36. My P&P List- Policies you need to review Policy and Procedure Manual—At a Minimum: –Patient Admission, Transfer, Discharge –Compliance with all Local/State Requirements Supporting evidence attached –Handling of Equipment –Storage of Equipment –Inventory Control and Management –OSHA and Infection Control –Performance Improvement (P.I.) and Data Collection ***Review the requirements of the company you select**

37. More of My List Employment and Personnel Policies –Include Written Job Descriptions and Org Chart Competency Assessment Program Sample Contracts-if you use them Personnel File for Each Staff Member –Files organized and kept in locked, secure area –Health information, DOB kept separately

38. Personnel Files Personnel File for Each Staff Member –Date of Hire –Evidence of Interview –Background checks –Driver’s License/Driving Record –Signed Job Description and Annual Evals –Signed Orientation Checklist –Competency Evals- on hire and annually See the specific requirements for the accreditation program you choose

39. CMS Final Quality Standards Consumer Services Provide clear instructions on use, maintenance and potential hazards of item(s) Provide expected time frame for receipt of delivered item(s) Verify item/service was received Provide contact information and options for rental or purchase Provide information and telephone numbers for customer assistance: Regular business hours, after hours, repair, emergencies

40. Complete Policy and Procedure Manual Must meet the needs and requirements of the accreditation provider you select Not worth trying to create on your own at this point

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

42. Common Items Found HR Charts –Complete –Annual Evaluations –Complete Hep B documentation –Medical/Health Info separated Patient Charts –Incomplete documentation of receipt of paperwork –Forms not witnessed, dated, completed as indicated

43. Reality Fact: –Your P&P should have everything you need to meet accreditation guidelines

44. #2 Infection Control What Happens?

45. Infection Control and Surveillance Manner in which items are cleaned, serviced, stored (clean – dirty)-logs Decontamination, OSHA issues, safety equipment and training Reporting of infections: patient or staff Personal protective equipment Visits/patient contact- handwashing Retail- customer rest rooms

46. What Other Common Infection Control/Safety Issues Are Found? Infection Control: – Clean vs. Dirty- Warehouse, trucks –Handwashing Chemicals scattered throughout Labeling/placarding Fire Drills Conducted Annually Fire Extinguishers Current Stacks of forms/Trash Trucks not clean, up to date on maintenance

47. Reality Fact: –Infection Control is one of the main tenants of accreditation –You can not review enough –A revisit is really the only way to observe if infection control practices are being observed

48. #1 Lack of Physician Orders What are the Most Common Problems?

49. Problems Oxygen CPAP Hospice

50. Reality Fact: –HUGE issue –EASILY addressed Prescriptions Discharge Orders Hospice Standing Orders

51. Solutions PLENTY of Staff Training Chart Audits Orders Conduct Your Own Mock Survey

52. Home Visits GO OUT AND SEE WHAT’S HAPPENING!!! Surveyors will interview patients, asking how they were oriented, how to reach the office, how the services has been, any problems…

53. Time Issues Current accreditation programs suggest that organizations should have at least a 3-month history of performance improvement data collected and be implementing systems prior to an accreditation visit Small organizations often take at least 3-4 months to complete a “self-study” CMS Deadlines Most surveys are scheduled at least 1- 2 months in advance

54. The Most Effective Way to Survive and Thrive in Your Business is to Be Prepared

55. Your Questions…

56. Thank You! Mary Ellen Conway President Capital Healthcare Group, LLC Bethesda, MD 301-896-0193 www.capitalhealthcaregroup.com