Your Ultimate Checklist for Mastering Home Health Surveys (Part 2)

Surveys are heavily focused on data, which serves as evidence of your agency's practices. Create a "Survey Book" (physical or electronic master index) that contains all required documents for immediate access.

Key Documents to Have Ready:

1. Patient Census Lists:

o Currently active patient census (with start-of-care, diagnosis, and disciplines).

o Unduplicated census list for the past 12 months.

   2.  Staffing & Personnel:

o Active staff list (including contractors) with titles, disciplines, and hire dates.

o Complete and current Human Resources (HR) files for all personnel, including evidence of background checks, up to date licensure, competency evaluations, and annual training. All personnel files should be up to date with supervision visits and evaluations.

   3.  Operational & Compliance Records:

o Current licenses/permits and organizational chart.

o Quality Assessment/Performance Improvement (QAPI) plan and associated performance improvement projects (PIPs), with evidence of tracking, trending, and analysis.

o Infection Control Program logs, policies, and the Annual Agency TB Assessment, Employee Hepatitis B immunization, and yearly flu vaccine (if required by your agency)

o Emergency Preparedness Plan (EPP), including documentation of training and drills/exercises. These drills are unannounced prior to the Administrator declaring the emergency. The After Action Report lists the emergency,  selected members of the team,  and timing of the staff response to the activation of the Emergency Plan/

o Minutes from governing body and QAPI meetings.

The Power of Policies & Procedures (P&Ps)

Ensure your P&Ps are not only up to date with current state and federal regulations (especially the Conditions of Participation - CoPs),  but are also understood and followed by all staff.

Common areas of focus include:

1. Patient Rights (including complaint procedures)
2. Comprehensive head-to-to-toe assessments and care planning that reflects the findings in the assessment and patient’s wishes for services.
3. Infection Control and Prevention
4. Skilled Professional Services (e.g., nurse/aide supervision)

Any time changes are made to the policies and procedures that impact the caregivers in the field,  there should be evidence of the changes and that all staff were informed of what is now expected. To ensure compliance, it is recommended that all staff receive a copy of the new policy and procedure and sign they have been instructed and understand the changes in practice that are now expected. Always document these sessions as training and education and make sure that copies are in all the personnel files.

This concludes Part 2 of the survey master list for survey success. Should you need additional assistance with survey preparation, please contact Kenyon Homecare Consulting online or call us at 206-721-5091