1. Know the Rules of the Game and how to apply them.
Familiarity with the Federal Conditions of Participation, State Licensing Standards, Accrediting Body requirements and your agency‘s policy and procedure is essential. Regulations require that there is a designated “Compliance Officer” in your organization. Take this position seriously. Designate someone within your agency who is knowledgeable and capable of helping to keep your organization compliant. National and State Home Care Associations are very helpful in providing updates to regulatory requirements. The person appointed should be able to sort through the regulation and apply the information to your agency. Your agency’s compliance officer will also be saddled with the responsibility of educating other staff members on regulatory changes that affect your organization. When regulations change, the compliance officer is required to educate other staff and assist with the implementation of the new requirements. For smaller agencies a third party such as a reputable consultant or consulting company will be beneficial in carrying this out.
2. Maintain an Efficient Records Process
When a surveyor walks into a Home Health Agency in the state of Texas they will typically always ask for;
The current patient list (sometimes referred to as an unduplicated census), the discharged patient list, the current employee list, the policy and procedure manual, the complaint log, the incident report log, the infection log and Quality Assurance (QA) data. This first bit of exchange frequently will set the tone for the survey. Write down everything the surveyor asks for and strike through each item as you are providing it for review. If this information is available and easily accessed you are on the right track. Remember first impressions are important and difficult to change. If all the information requested is not available, give the surveyor what you have and include additional items as you have them accessible. Whatever you do, give the surveyor something. Never leave a surveyor waiting with nothing to do.
3. Designate a staff member to be the agency’s primary representative during the survey.
At the beginning of a survey, a primary representative should be established. Assigning a competent staff member as a compliance officer gives your agency a single point of reference and streamlines communication within the agency and with the surveyor. This point of contact is the person assigned to answer the surveyor’s questions, provide copies of medical records when requested and keep a log of all the questions asked. Two copies of what the surveyor requests should always be made, one for the surveyor and one for the agency. This will give some insight into how the survey is going. The appointed person should be an administrative assistant or an office manager, ideally someone who can stay calm and knows where to find answers. This will decrease random inquiries to other staff members in the office. The Administrator and Director of Nursing or their alternates should be available at all times to answer questions that sometimes only they can answer. Federal and State rules regulate agencies’ activities. It is the responsibility of the agency leaders to ensure that the agency adheres to and operates within these guidelines. There are constant changes in the home care industry and there is a lot to learn. It is important that agency leaders provide training opportunities for their staff so that employees are knowledgeable within their job description and position requirements. When employees respond to the surveyors by saying, “I don’t know”, it gives the impression that the leadership is not channeling information to appropriate staff members. In contrast, too much or incorrect information can be just as harmful. A more appropriate answer is, “I’m not sure about that, let me get someone who can better answer that” or, “let me check on that for you”. The impression that should be given to a surveyor is that individuals within the organization know where to get answers.
4. Don’t let the surveyors see you sweat.
Have a positive attitude, do not take the survey personal and ALWAYS keep your cool. Set the tone of the survey by being proactive and prepared . If you have been “reacting” to requests by the surveyor rather than “providing” information, the survey will probably not go well. Hence; always be prepared. If you find during the survey process that you are not prepared, stay calm as there is only so much you can do. Communicate potential problem areas with key staff and set out addressing such discrepancies. Demonstrate to the surveyor how great an organization your agency is and how important patient care and safety is to you. Let the surveyors know that patients are always first. Be cooperative and communicate to the surveyor your willingness to learn and do things right.
5. Always be prepared.
The mindset of your organization should always be that a surveyor can walk in at any time. There is no substitute for being prepared. Have all records filed accurately for easy retrieval. This gives the perception of an organized agency that is compliant with all that is required. Assigning a staff member to stay abreast of regulatory changes and educate other staff will help your organization stay prepared at all times. Typically your compliance officer will get better at performing such a role with practice and familiarity with various sources of regulatory information. Contracting with an experienced third party to perform regularly scheduled quality assurance audits will help your agency stay prepared and can provide valuable insight into the level of readiness of the organization for a state survey. Consultants or consulting companies usually provide ongoing regulatory updates to help keep agencies compliant
