With CMS intensifying its oversight on hospice and home health organizations, adapting to a...
With CMS intensifying its oversight on hospice and home health organizations, adapting to a proactive compliance posture is essential. There are no more prior notification of surveys, no more block out days, CMS will take over validation surveys by sending in a CMS contracted agent with the Accrediting Organization simultaneously to co-conduct the survey, and state complaint surveys may turn into full validation surveys. The only way to be ready for surprise surveys is to stay survey ready at all times. This blog series lays out the Five Most Important Steps to achieve Perpetual Survey Readiness.
Step 5: Training and Transparency
Don’t let the surveyor be the first person to observe field staff in action.
The final step in obtaining perpetual survey readiness is training and transparency, where you put the previous steps together to ensure that everyone in your organization is ready to present to a surveyor and answer their questions at any time.
The first measure that can be taken to ensure survey readiness amongst the whole organization is auditing staff knowledge and competency. Important questions to ask include:
- Is your field staff familiar with QAPI and why it’s so important?
- Do your field staff members know your performance improvement projects (PIPs), and could they speak to them if a surveyor asked?
- Are your field staff members adhering to all policies and guidelines such as hand hygiene and medication management, and could they produce them during a survey?
Next, it is important to provide training and education on compliance and quality, training to answer questions such as why QAPI is important, what your organization is doing to address issues that may arise in the field, as well as what are the current PIPs and why they are so important to bettering care.
Home health and hospice agencies must provide transparency into their quality improvement efforts for the whole organization. Not only is it important to distribute copies of PIPs and frequently used policies and procedures, but it is also crucial to foster a culture of safety by sharing incidence reports organization-wide in order to learn from mistakes.
No field staff member wants to be caught unprepared for a surprise survey, so training field staff in how to handle an unexpected survey is vital so they can rise to the occasion. The best way to prepare field staff is to go out with them often and practice conducting home visits with a surveyor observing.
When conducting these mock survey visits, make sure to observe field staff completing comprehensive patient assessments, as well as their techniques and practices for:
- proper infection control
- proper equipment cleaning
- proper bag technique and hand hygiene
- proper medication reconciliation process and keeping the patient’s medication profile up to date.
In addition, auditing patient home binders for and organizing important documents can help a field staff member streamline the survey process. Important documents to organize include:
- Consent form copies
- Updated medication profiles
- Updated and accurate care plans
- Patient specific emergency management form with an evacuation plan
- Agency contact information
- Patient rights documents
Don’t let the surveyor be the first person to observe field staff in action.
Make sure they’re perpetually prepared for any surprise surveys with QAPIplus. With QAPIplus your staff will be able to access survey-readiness resources such as your organization’s PIPs and your frequently used policies and procedures.
In addition, QAPIplus makes it easy to conduct and report on joint supervisory visits and hand hygiene audits in the field using our mobile app to document competencies and compliance.
To learn more about how QAPIplus increases staff transparency into your quality programs and helps your staff be prepared for a surprise survey, request a demo today.
Read more blog posts about survey readiness, quality, and compliance management.
