Preparing for a home health survey: Part 2
To remain in substantial compliance with Medicare and state law, CMS expects home health providers to continuously monitor performance and establish policies to correct deficient practices to promote correction that is lasting.
In the second part of this blog series on home health survey preparedness, we explore how to implement an effective plan of correction.
What is a plan of correction?
A plan of correction is a plan developed by a home health agency (HHA) and approved by CMS that is the HHA’s written response to survey findings detailing corrective actions to cited deficiencies and specifies the date by which those deficiencies will be corrected.
Developing — and more importantly, implementing — an effective and acceptable plan of correction involves more than responding to cited deficiencies with written plans to correct them. It requires an analysis of all deficiencies identified to determine whether the underlying root cause of each problem is isolated or a system issue.
Corrective actions should be inclusive of education, new policies, procedures and processes that will not only correct each deficiency, but also support ongoing compliance. This is achieved by helping to ensure underlying causes of problems do not recur and lasting changes are made within the agency that will improve quality, safety and care delivery for all patients served.
Here are six steps to implementing an effective plan of correction:
Step 1: Prepare for a survey entrance and exit
The process of developing and implementing an effective plan of correction begins the moment a surveyor enters the building. Throughout the survey process, HHAs have the right to request clarification of any surveyor comments, statements or expressed observations, offer additional evidence of compliance to the surveyor(s) to clarify and/or refute negative findings, and request the resolution of conflicts with the surveyor(s) from the State Agency (SA) and/or the CMS Regional Office (RO).
Some surveyors may afford your agency the opportunity to sit with them for a brief daily exit conference to review their observations and findings from the day and provide your team an opportunity to clarify and bring forth more supporting evidence of compliance. Regardless of whether the surveyor team holds a daily exit conference or not, it is highly recommended that your agency survey response team come together daily after the surveyors leave for an exit debrief. This is an opportune time for the team to review observations and potential findings that occurred throughout the day. Documentation requested and provided can be reviewed, along with all scribe notes. If your agency was afforded the opportunity to send escorts on survey home visits, this is also a great opportunity to review observations and scribe notes of how the visits went.
If the surveyors are giving consistent feedback daily as your survey progresses (and they should be — request it if you do not feel it is consistently being provided), your team should have a good understanding of problems as they are identified each day.
Step 2: Perform a post-exit debrief after the survey exit conference
The surveyor(s) should provide an exit conference at the conclusion of the survey before they exit your agency. The purpose of the exit conference is to provide a forum for the surveyor(s) to meet with HHA leadership and staff to inform them of the observations and preliminary findings of the survey. It serves as a forum for the surveyor(s) to educate the HHA on regulations, provide the (preliminary) informal review of deficiencies, and advise the HHA of next steps/what to expect in regard to receiving their final statement of deficiencies and instructions for completing and submitting a plan of correction.
After the exit conference convenes and the survey team has left the agency, HHAs should start to work on developing and implementing action plans immediately, starting with a post-survey debrief to summarize the preliminary findings and deficiencies reviewed to ensure all information and instructions presented by the surveyor(s) were accurately captured and documented. It is also a great time to forecast which standards may be cited in your final statement of deficiencies, inclusive of the potential for cascading deficiencies and/or conditional level citations, so that a focused plan can be initiated.
This debrief is an opportunity to assign action items for follow-up, and to start collaboration on the necessary steps to begin developing an effective plan of correction. HHAs should not wait until they receive the final statement of deficiencies to determine necessary corrective actions.
Step 3: Develop a plan of correction
The corrective action process requires HHAs to develop and implement policies and procedures to both remedy deficient practices immediately and to help promote corrective actions that are lasting. This process begins with determining the root cause by first analyzing each deficiency to determine what happened and why the problem exists, which will make it easier to address the needed corrective action elements within your HHA’s plan of correction:
- Why did this occur?
- Is this related to a knowledge deficit?
- Was there something we should have been doing, but did not?
- Is this an isolated incident?
- What systems were lacking or incomplete?
Once this discovery and analysis of the root cause of each problem is completed, your HHA is ready to write your plan of correction — which needs to address the “who,” “what,” “how” and “when.” This should follow CMS’ list of required elements that must be included in an acceptable plan of correction:
- The plan for correcting the specific deficiency (“what” is the plan?)
- The procedure for implementing the acceptable plan of correction for the specific deficiency cited (“how” will the deficiency be resolved, and “when” will it be corrected?)
- The monitoring procedure that will ensure the corrective action is effective, and that the specific deficiency remains corrected and/or in compliance with regulatory requirements (“how” will effectiveness of the plan be measured?)
- *A general statement indicating compliance has been achieved or will be achieved will not be acceptable, as the plan of correction must state exactly how the deficiency has been or will be corrected, and how the HHA will measure effectiveness of the corrective actions and assure it will not recur.
- The title of the person responsible for implementing/monitoring the acceptable plan of correction (“who” is responsible for the plan?)
Step 4: Submit the plan of correction
Once the plan of correction is developed, agencies submit the plan and confirm it has been both received and deemed acceptable (there are serious consequences for not following submission requirements). Additionally, state and federal enforcement processes are independent of the plan of correction process. Enforcement actions, such as terminations, may not be delayed even if the HHA’s plan of correction is late or needs revision to become acceptable.
Step 5: Implement and monitor the plan of correction
Implementation of the plan of correction should be inclusive of establishing measures or systemic changes that will prevent the deficient practice(s) from reoccurring. “Owners” should have been assigned to be responsible for implementing (includes monitoring) specific corrective action plans for each deficiency. Monitoring should continue, even after the deficient practice has been corrected for an established period of time to assess the effectiveness of the corrective actions and to make sure that the problem(s) will not recur.
Organizing all supporting documentation with your plan of correction serves as evidence that your plan was implemented, deficiencies have been corrected, and the corrective actions are continually monitored to make sure they are lasting.
The supporting documentation and data provide a foundation where your monitoring activities can be focused and incorporated into your agency Quality Assurance and Performance Improvement (QAPI) program for long-term success. Supporting documentation is inclusive of:
- All staff educational offerings and special trainings designed to correct deficiencies, inclusive of copies of agendas, sign-in sheets and any handouts provided
- Agendas, sign-in sheets and minutes for all management and staff meetings that are related to plan of correction activities
- Any audit tools created and used for testing and monitoring activities, along with all the data aggregated and analyzed, and summaries of the findings
- All new and/or revised policies and procedures need to be effectively documented, along with evidence of communication and training of them to staff
- New or revised processes or established systems also need to be well documented and tested for the desired impact and outcomes the agency wished to achieve
Step 6: Integrate with your QAPI program
Your agency’s QAPI program should always include the plan of correction activities on some level. For instance, your QAPI program activities are expected to focus on high-risk, high-volume and/or known problem areas. Your survey assessed the care and services your agency provides and the findings from your survey have identified problem areas, some of which might have also included high-risk or high-volume areas.
The scope and focus of your QAPI program should include objective measures to demonstrate improved performance that is sustained over time — inclusive of assessing the quality of care provided and identifying and prioritizing opportunities for improvement.
Schedule a QAPI meeting and review your plan of correction as the priority agenda item. Look at each deficiency and associated plan of correction. Some deficiencies may have easily been corrected and others may need extensive ongoing monitoring. Prioritize each one and align supporting documentation with performance improvement projects (PIPs) within your QAPI program.
Achieving substantial compliance with the Conditions of Participation (CoPs) is core to the care and services of which an agency provides, and your plan of correction activities can be seamlessly integrated into PIPs within your QAPI program. Work smart, not hard! Take credit for all the work your team has done and will continue to do.
Encourage engagement from staff on all levels, update staff on progress toward goals, and use visual displays in staff work areas. Everyone in your agency should know what your PIPs are and how your agency is measuring progress.
Lastly, keep your governing body informed. Create a structured and consistent system to report up. Secure meeting minutes and make sure any copies of reports or communications are also maintained.
Is your home health organization ready to implement an effective plan of correction? Connect with us today to learn how MatrixCare tools can help you continuously monitor performance.
Brandy Shifteh
Brandy Shifteh, RN, BHSA, MBA, joined MatrixCare in April of 2018 as a Clinical Informatics Business Analyst, where she has been very involved in the development and enhancement of clinical analytics that supports scrubbing of OASIS assessment data, casemix/HIPPS scoring, clinical assessment reviews and coding. In April of 2019, she transitioned into a Regulations Compliance role, where she is responsible for monitoring regulations that impact home health, hospice and private duty home care, to help ensure our solutions support all existing and new regulations. She is very plugged into the regulatory community with relationships at both the state and federal level and serves as an active member on the National Government Services (NGS) Vendor Coalition group, where she provides input on MAC provider education and materials. Brandy is a Registered Nurse and comes to us with over 23 years of operations management experience in the home health, hospice and private duty home care sector, inclusive of accreditation/survey preparedness, compliance and clinical/quality improvement programming. She holds two undergraduate degrees; science and nursing and health services administration; and an MBA in computer information systems (CIS).
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