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Top Ten Problems Found on Survey. MedTrade Spring Wednesday, April 25, 2007. Mary Ellen Conway, President Capital Healthcare Group. Top Ten Problems On Survey. Learning Objectives: What is the format of a survey? How can you prepare? What is reality and what is a myth?

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top ten problems found on survey

Top Ten ProblemsFound on Survey

MedTrade Spring

Wednesday, April 25, 2007

Mary Ellen Conway, President

Capital Healthcare Group

top ten problems on survey
Top Ten Problems On Survey

Learning Objectives:

  • What is the format of a survey?
  • How can you prepare?
  • What is reality and what is a myth?
  • The top 10 problems found and how you can avoid them
where do we begin
Where Do We Begin?
  • What is the typical format of the survey?
    • Now all are unannounced
    • Formats
      • JCAHO Tracer Methodology
      • Review of Patient Lists, Personnel Lists, Patients Scheduled for Visits
two day survey
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

more on a two day survey
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

before we begin
Before We Begin
  • Ensure that you have worked through your accreditor’s standards
    • Make sure your policies and procedures are aligned with the accreditation company’s standards
    • You have completed all requirements
cms final quality standards
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.)
  • Compliance with these standards will be enforced through the accreditation provider you select
10 psychotic surveyors
#10 Psychotic Surveyors

Myth or Reality?

is it myth or reality

You are the accreditor’s customer

You have ways to appeal

You need to be prepared!

Is it Myth or Reality?
in preparation create your checklist
In Preparation, Create Your Checklist
  • Develop your own or purchase one
  • Check to make sure you have everything you need on your list
    • Review your standards/guidelines
    • Make sure each aspect of your services and ALL types of services you provide are addressed (retail, delivery, on-line?)
creating your checklist
Creating Your Checklist
  • Warehouse/layout
  • Educational Calendar
  • Staff and Patient Interviews
  • Infection Control and Surveillance
  • Performance Improvement/QI
  • Personnel Files
  • Patient Records
  • Home Visits
keep in mind any other compliance that might be assessed such as hipaa
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?
p i q i programs p erformance or q uality i mprovement
P.I./Q.I ProgramsPerformance or Quality Improvement
  • Usually the one area that organizations have not had in place prior to the pursuit of accreditation
  • Can be done internally without outside assistance---but may require benchmarking
  • Focuses on item/area that can be monitored and improved (Customer Satisfaction)
p i q i programs
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)

Second Quarter

Washington, Division

FY 2006

Performance Management
  • Beneficiary satisfaction surveys
  • Patient complaint log
  • After hours (on call) log to prove timeliness of response to questions, problems and concerns
  • Log that documents frequency of billing and/or coding errors
  • Log documenting adverse events (as defined by your P & P manual)

Most accrediting organizations require at least three months of surveys collected and summarized with plans for improvement or you will have to provide written follow-up and possible a re-visit

is it myth or reality19

Everyone needs to know what’s going on

You can not do things in a vacuum

Everyone needs to be prepared!

Is it Myth or Reality?
8 no ride alongs
#8 No Ride Alongs?

Bad Idea– Myth!


There is no insurance issue

If questions are not asked during the ride, they will be asked at other times

Practice interviews, safety issues


7 inventory management
#7 Inventory Management

What is Required?

final supplier quality standards
Final Supplier Quality Standards

2 Sections

First Section: Business Services

  • Administration
  • Financial Management
  • Human Resource Management
  • Consumer Services
  • Performance Management
  • Product Safety
  • Information Management
cms final quality standards24
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
cms final quality standards25
CMS Final Quality Standards

Product Safety

Equipment management program that promotes the safe use of equipment and minimizes safety risks and hazards including:

  • Plan for identifying, monitoring and reporting failures, repair and preventive maintenance
  • Investigate any accident or injury (within 72 hours or 24 hours if results in hospitalization or death)
  • Contingency plan for response to emergencies and disasters
Must Comply With:

CMS Final Quality Standards

Your Accreditor’s Requirements

6 competency program
#6 Competency Program

What is Required?

cms final quality standards28
CMS Final Quality Standards

Human Resource Management

Implement policies on:

Specific qualifications



Continuing education requirements

Technical personnel:


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

competency program
Competency Program
  • Review the requirements of your accreditor and be sure you meet them
  • Generally only technical staff are required to have competency evaluated
  • Must be observed for technical staff
is it myth or reality30

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

Is it Myth or Reality?
is it myth or reality32
It’s an UrbanLegend!

You are held accountable for following your own Policies and Procedures

Is it Myth or Reality?
4 preventive maintenance
#4 Preventive Maintenance

What Do I

Need to Have



You need to be able to explain your program for Preventive Maintenance on appropriate items

How to identify items in the field that need it

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

3 policies and procedures
# 3 Policies and Procedures

A “MUST HAVE” in order to become accredited

my p p list policies you need to review
My P&P List- Policies you need to review
  • Policy and Procedure Manual—At a Minimum:
    • Patient Admission, Transfer, Discharge
    • Compliance with all Local/State Requirements
      • Supporting evidence attached
    • Handling of Equipment
    • Storage of Equipment
    • Inventory Control and Management
    • OSHA and Infection Control
    • Performance Improvement (P.I.) and Data Collection

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

more of my list
More of My List
  • Employment and Personnel Policies
    • Include Written Job Descriptions and Org Chart
  • Competency Assessment Program
  • Sample Contracts-if you use them
  • Personnel File for Each Staff Member
    • Files organized and kept in locked, secure area
    • Health information, DOB kept separately
personnel files
Personnel Files
  • Personnel File for Each Staff Member
    • Date of Hire
    • Evidence of Interview
    • Background checks
    • Driver’s License/Driving Record
    • Signed Job Description and Annual Evals
    • Signed Orientation Checklist
    • Competency Evals- on hire and annually
  • See the specific requirements for the accreditation program you choose
cms final quality standards39
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

complete policy and procedure manual
Complete Policy and Procedure Manual
  • Must meet the needs and requirements of the accreditation provider you select
  • Not worth trying to create on your own at this point
complete paperwork for patients
Complete Paperwork for Patients
  • Such as:
  • Consent for Treatment/Services
  • AOB
  • Third Party Review
  • HIPAA Information
  • Disaster/Emergency Preparedness
  • How to Reach the Office (Hours)
common items found
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

Your P&P should have everything you need to meet accreditation guidelines

infection control and surveillance
Infection Control and Surveillance
  • Manner in which items

are cleaned, serviced,

stored (clean – dirty)-logs

  • Decontamination, OSHA issues,

safety equipment and training

  • Reporting of infections: patient or staff
  • Personal protective equipment
  • Visits/patient contact- handwashing
  • Retail- customer rest rooms
what other common infection control safety issues are found
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

Infection Control is one of the main tenants of accreditation

You can not review enough

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

1 lack of physician orders
#1 Lack of Physician Orders

What are the

Most Common


  • Oxygen
  • CPAP
  • Hospice

HUGE issue

EASILY addressed


Discharge Orders

Hospice Standing Orders

  • PLENTY of Staff Training
  • Chart Audits
  • Orders
  • Conduct Your Own Mock Survey
home visits
Home Visits


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

time issues
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
thank you
Thank You!

Mary Ellen Conway


Capital Healthcare Group, LLC

Bethesda, MD