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Think your agency is prepared? GAO report changes face of state surveys
Surveyors focus on problems, cite more deficiencies
It started out as a normal planned survey at Visiting Nurse Health System (VNHS) in Atlanta. However, during the six weeks between the original survey in June and the resurvey, a complaint came in, changing the focus of the resurvey. The deficiencies cited as a result of the review survey placed the agency in jeopardy of losing its Medicare participation status.
"We were notified on Aug. 8 that we had 21 days to correct all the deficiencies or we would lose our Medicare status," says Pat Reid, RN, vice president of development for the home health system, which serves more than 20,000 patients throughout a 26-county area in Georgia.
Although existing patients continued to receive their regular visits, the agency stopped taking new admissions to enable staff members to focus on correcting the deficiencies and implementing a process to communicate with employees on a daily basis so they would know how things were going and could answer questions from patients and families. The strategy worked, with an Aug. 27 exit interview that generated compliments from surveyors as to the speed and thoroughness with which VNHS responded, she adds.
The best news is that once insurers and other referral sources were notified that the agency was again accepting new patients, all of the business returned, says Reid.
While it’s unusual for a home health agency to receive deficiencies that jeopardize its Medicare status, it easily can happen, even to an agency with a good record. The deficiencies for which VNHS were cited mostly were related to documentation and notification of physician, says Reid. "We never knew who called the state agency to complain about our care of a diabetic patient whose leg had to be amputated when it became gangrenous," she says. "The patient did not file the complaint," she adds.
The state survey environment has changed a lot since the General Accounting Office (GAO) issued a report in summer 2002 that reported inconsistencies and shortcomings in the oversight of home health agencies throughout the country. Specific states, including Georgia, were identified as not following up on complaints in a timely manner, not reviewing an adequate number of charts, not citing deficiencies properly, and not resurveying in a proper manner. Although state surveyors say the GAO report has not influenced their survey practices, many home health managers contend that it must have had some effect.
"The environment has changed since the GAO report," says Reid. "We get about 12 complaints each year and have never had this experience. The survey is usually no problem, and there has never been any difficulty resolving the complaint," she adds.
With the changing approach of state surveyors as a result of the GAO report and the use of the Outcome and Assessment Information Set (OASIS) data to focus surveys, what can home health agency managers do to prepare for surveys and not be surprised?
"Check with your state home care association to see if there is a group that either meets with or gathers information from the state survey agency on a regular basis," suggests Sherry Thomas, BSN, MPH, senior vice president of the Association for Home & Hospice Care of North Carolina in Raleigh. "Our association produces quarterly reports that show licensure and certification trends, including deficiencies, as well as complaint trends," she explains.
"Our membership uses the information to review their own agency’s performance and address issues that show up in surveys," Thomas adds.
Look at state trends
As the GAO report noted, survey practices differ from state to state, so while there are national data available, it’s best to look at trends within your own state, suggests Thomas. Although the data are available to compare trends from state to state, that can be misleading, she points out. "Some surveyors may cite a deficiency in one standard, while another state’s surveyor may cite the same item as a deficiency in another standard," she says.
Surveyors within the same state may differ as well, says Brenda Beggs, RN, CHCE, administrative director, Denton (TX) Home Health Care.
"We are part of a system that has home health agencies in two different survey zones, and when managers compare notes on surveys, we find that what is acceptable to surveyors in one zone is a deficiency to a surveyor in the other zone," she says.
Another way in which state surveys may change is the use of OASIS data to focus surveys, Thomas says. "Surveyors in our state [began] their training on the use of OASIS data in their pre-survey process in December ," she says.
The tool used to analyze OASIS data prompts surveyors to make sure home health agencies have policies and procedures that cover all aspects of receiving, tracking, entering, and transmitting OASIS data, as well as policies that cover how the agency handles OASIS data if another vendor is handling the entry and transmission, she says.
That is important for home health agencies because managers need to make sure they are getting their own OASIS reports and not just relying on the vendor to provide updates or alerts, Thomas adds.
"Surveyors want to see that home health agencies are reviewing and using OASIS data to monitor their performance," she explains.
Surveyors also will ask home health agency managers to print out a final validation report for four to six records showing at least one assessment sent to the state. "This means that agency personnel have to be familiar with OASIS and be able to provide the validation reports when asked," Thomas points out.
Surveyors in Alabama have been using OASIS data to focus their surveys for several months, says Carolyn Duck, RN, supervisor of Medicare Other Unit for the Alabama Department of Public Health in Montgomery. "Our surveys are more focused, and we’re able to concentrate on areas that appear to be potential problems for agencies," she explains.
Although Duck says that the GAO reports did not affect the way her surveyors approached agencies, she does say that they are seeing more condition of participation-level deficiencies than they have in previous years. "Most of the deficiencies are related to documentation issues," she says. For example, a surveyor may not see any notes in the chart related to a wound assessment before treatment, she explains. Although the nurse most likely performed the assessment, if it is not written in the record, the surveyor has to assume the assessment didn’t occur, Duck says.
The type of deficiency raises questions as to whether the nurse was too rushed to do his or her paperwork because of workload, or in some cases, the nurse may be unfamiliar with the computerized charting system, causing him or her to chart incorrectly, she suggests.
Even when cited for deficiencies, a home health agency has to look at surveys as a chance to improve, Reid says. "We now have teams composed of six nurses and two social workers, and each team manager is paired with a quality-improvement person to review charts and educate team members on a regular basis," she says. "Our medical director is also more involved and meets on a weekly basis with the clinical personnel to discuss our sickest patients."
One thing VNHS staff discovered is that they often were taking patients that were too sick for home health care, says Reid. "It’s much easier for our medical director to talk to the hospital or referring physician and convince them that the patient may not yet be ready for home health care than a nurse," she says.
The medical director’s involvement has made it possible for the patient to get care in the best setting and when the patient does enter home health care, the medical director stays involved in the case, Reid adds.
As the memories of a hectic three weeks of seven-day workweeks fade, Reid does admit that it was a good learning experience for both VNHS and the state survey agency.
"Although the deficiencies threatened our Medicare status, the experience has made us a better organization," she says.
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