After a survey, receiving findings of deficiency can seem insurmountable. You’ve already worked hard to get where you are. Where is the time to improve upon what you’ve already done? Before you panic or feel overwhelmed, take a deep breath. You have options.
Let’s start with understanding the basics of the surveys. When you understand the components, you can break each down to better evaluate your home health or hospice agency.
The Process of Surveys
Whether a routine initial survey or a 36-month resurvey, the visits will be unannounced. Other reasons for surveys—also unannounced—could include change of ownership, reactivation of billing, changes in services, a branch addition, or validation. Because they’re unannounced, home health agencies must be prepared at any time.
If a home health agency is found to be in compliance with all Level 1 standards, or those most related to patient care, the survey will end. However, if noncompliance is found, Level 2 standards—those moderately related to patient care—will then be surveyed. With deficiencies at Level 2, Level 3 will then be surveyed.
Deficiencies fall into two main categories: those at the standard level and those that are on a condition level. Standard-level deficiencies are those that indicate noncompliance with one or more of the standards that make up each condition for participation as a home health agency, and can result in expensive penalties. A condition-level deficiency is one that limits the provider’s ability to provide adequate care or threatens the health or safety of patients. Failure to address condition-level deficiencies could put you at risk of losing your Medicare certification.
Plans of Correction
If found deficient, a written Plan of Correction is required. These plans describe the actions your facility will take to correct the deficiencies, as well as the date by which you will correct these deficiencies. You can think of this as your pledge to become compliant as soon as possible.
In order to adequately address each finding in the survey, take notes as the survey occurs. You may even want to begin writing the Plan of Correction during your inspection. After all, your plan is a legal, binding document due ten days after receipt of notice of deficiency, so you won’t want to miss any details.
If you do feel overwhelmed or lack the experience necessary, assistance can be provided. Many consulting firms can provide Plans of Correction written by professionals with in-depth knowledge of nursing facilities and the components of the inspection.
Before your next survey, prepare with a mock survey. Mock survey consultants simulate an inspection so that you can address any potential deficiencies before the official inspection occurs. Your team will also get the benefit of experience, which will give them more confidence during the next inspection.
Mock survey consultants will provide a comprehensive evaluation of your compliance risks, as well as suggestions for resolving them. This is also a great opportunity to gain more experience writing a Plan of Correction, even if you hope not to need it for the official survey.
As you can see, there is no reason to panic if you receive findings of deficiency. Your best course of action is to start planning now for your next survey, but if you’re in need of a Plan of Correction right away, reach out now. We can help ease the burden and help you prepare for the future.