Master Medicare Surveys: The Essential Binder for Home Health & Hospice

Preparing for a CMS survey in home health or hospice requires shifting from "crisis mode" to a culture of continuous compliance. Because surveys are unannounced, agencies must be ready every day.

1. Build a "Survey Readiness Book."

Create a central digital or physical Survey Book that contains everything a surveyor will request within the first hour. This prevents panic when the receptionist announces, "The surveyors are here." Key items include:

· Organizational Essentials: Current organizational chart, all state licenses, and CLIA waivers.

· Patient Data: A list of active patients with admission dates, diagnoses, and their scheduled visit dates during the survey week.

· Reporting: Unduplicated admission counts for the past 12 months and a list of discharges/transfers.

· Contracts: Current agreements for pharmacies, DME, and contracted staff.

2. Focus on "High-Deficiency" Areas.

CMS data shows that most citations fall into a few predictable categories. Proactively audit these areas:

 · Individualized Plans of Care: Ensure care plans are specific to the patient's unique needs (e.g., specific swallowing techniques for dysphagia) rather than "cookie-cutter" templates.

· Medication Management: Review medication profiles for potential adverse reactions and ensure they match the current physician orders exactly.

· Infection Control: Surveyors frequently cite hand hygiene and improper PPE use during home visits. Demonstrate continuing education that ensures compliance with these requirements. ALWAYS WASH IN AND OUT OF A HOME AND ACCORDING TO YOUR POLICY AT A MINIMUM!

· Aide Supervision: Verify that hospice/home health aides are supervised according to the required 14-day cycle.

3. Conduct Mock Surveys and Staff Drills.

Simulation is the best way to identify gaps before the state agency does.

· The First 30 Minutes: Practice the entrance conference and ensure multiple staff members know how to pull records from your EMR.

· Staff Interviews: Ask field staff typical surveyor questions: "How do you know this patient is eligible?" or "What do you do if you suspect patient abuse?"

· Tracer Audits: Follow a "patient’s story" through their chart to ensure interdisciplinary team (IDG) notes support the plan of care and document the patient's decline or progress.

4. Maintain Environmental and Safety Compliance.

 · Emergency Preparedness: Ensure your Emergency Preparedness Plan (EPP) includes a site-specific risk assessment and proof of annual training and drills.

· Physical Office: Check that supplies are not expired and that exit signs and fire extinguishers are maintained.

5. Leverage Quality Programs (QAPI)

Use your Quality Assessment and Performance Improvement (QAPI) program to provide evidence that you are self-correcting. If you found an error in the past year, show the surveyor how you identified it, the plan of correction you implemented, and the data proving it’s now resolved. As with your ongoing survey readiness, someone is required to ensure that all elements of the survey readiness book are completed.

If you need assistance with survey readiness, contact Kenyon HomeCare Consulting. We can provide an organizational assessment/ mock survey with a report of areas that require immediate corrective action to ensure survey success. For assistance, call 206-721-5091 or email gkenyon@kenyonhcc.com.