The road to zero deficiency: How to achieve survey success

Achieving a deficiency-free survey doesn’t happen by chance or through simply maintaining good policies. It requires a coordinated effort at every level of the organization, with a constant focus on delivering patient-centered care. Here are four key considerations that agencies should prioritize on their path to achieving zero deficiency.

1. Understand the regulations

Home health and hospice are two of the most heavily regulated sectors in healthcare, governed by a complex mix of state and federal rules, as well as accreditation standards. Agencies must navigate a broad array of requirements, which means leadership must ensure that the entire organization is fully educated and prepared.

But compliance cannot rest solely on the shoulders of the executive team; it must be embedded throughout the entire staff. Only with a deep understanding of these regulations can an agency achieve a positive survey outcome.

2. Communicate the ‘why’ behind policies

Handing out policy manuals and procedures isn’t enough to foster a culture of compliance. Employees need to understand the rationale behind each policy. Explaining the ‘why’—why a procedure is followed, how it affects patient care, and the benefits of adherence—creates a sense of purpose and responsibility among staff.

When employees are engaged with the reasons behind regulations, they are more likely to integrate these practices into their daily routines, leading to better outcomes in compliance and patient care.

3. Master the four survey components

Surveys can happen at any time, so preparation is key. A typical survey will include four primary areas

• A review of medical records
• An examination of agency operations
• A study of policies and procedures
• In-home visits to observe staff in action

Agencies must continuously prepare their teams for these surveys by providing ongoing education on each of these components. By making preparation an ongoing process, agencies reduce the risk of non-compliance and are always ready for that unexpected moment when surveyors arrive.

4. Use data and resources to address deficiencies

Agencies must proactively learn from both internal and external data. This means understanding not only the deficiencies the agency may have faced in previous surveys but also the common pitfalls that other agencies experience.

By staying ahead of potential issues, agencies can address shortcomings before they become problems in the next survey. Corrective action plans should be developed and implemented to make sure the agency remains in compliance with all regulations.