Pre- survey Preparation Part II

Transcription

1 Pre- survey Preparation Part II April 12, 2010 Objectives: Discuss the purpose of pre-survey preparation. Discuss the use of the Pre-Survey Preparation Worksheet. Identify sources for information gathering pre-survey. Describe specific information to obtain from each source. 2 1

2 Objectives (cont) Discuss the analysis of information obtained during the pre-survey preparation. Provide examples of effective pre-survey preparation that facilitated the entrance conference and/or improved overall efficiency of the on- site survey. Apply webinar learning to future pre-survey activities. 3 What is pre-survey preparation? Gather information about the agency Type of provider Patient population Services provided Where do they provide services? Size Operator Agency characteristics/personality Compliance/Noncompliance history 4 2

3 Goals To know as much as possible about the agency before walking through the door! Get Organized Prepare survey team Reduce onsite surprises 5 Purpose: Assists in organizing and planning survey Focused Efficient Effective Determines type of survey needed Overlap (LHCSA/TBI) (CHHA/LTHHCP) Home Health Aide Training Program 6 3

4 Purpose: (cont) Identify: Patient population Unique agency characteristics Potential Issues/Problem Areas Areas to target 7 Purpose: (cont) Determine sample- patient records/visits Employee records/interviews Create cert kits Determine resources needed (staff and time) Assign team members 8 4

5 Pre-Survey Worksheet Worksheet use is optional but presurvey prep is NOT optional Guide for information gathering Planning tool Organize notes Modify if needed to meet needs Retain in Agency file -optional 9 Sources of Information Agency Paper File Aspen - ACO/ACTS Health Provider Network - HPN Casper Reports (CHHA/LTHHCP Only) 10 5

6 Paper File License Operating Certificate Ownership Information Approvals-locations, services, etc Correspondence Contracts approved by DOH Survey Info- SOD/POC Agency Changes 11 Review Survey history: Date and Type of Survey Re-licensure/Recertification Standard/Extended Partial/Consolidated Complaint Was SOD issued? Was POC acceptable and approved? 12 6

7 Review SOD for following: Was a revisit conducted? Identify Major Issues to investigate on survey Administration/ Governing Body Supervision QA Plans of Care 13 Review POC for following: What is agency supposed to do to fix the major issues/problems? How is the agency going to monitor their plan and effectiveness? Identify areas to investigate on site 14 7

8 Aspen Central Office (ACO) Full Facility Profile- tags cited, services approved, administration/owner info Compliance History- survey dates, type and findings Facility Properties- Notes area for NHTD/TBI waiver 15 Aspen Complaint Tracking System (ACTS) Review all complaints open and closed Depending on volume go back 6 months to 3 years 16 8

9 Closed Complaints Review closed complaints for: Allegations Findings Trends 17 Open Complaints Record Log #s Initiate complaint investigation pre-survey (phone calls) Determine Potential Sample (home visit/interviews) 18 9

10 Opened Complaints (cont) Address and Investigate during Survey Close all open complaints on survey Identify Patterns/Trends to investigate onsite (aide service, quality of care, patient rights) 19 NHDT/TBI Review Serious Reportable Incidents Is investigation needed? Are there trends? 20 10

11 Health Provider Network- HPN Communications Directory (Role lookup tool) HPN Coordinator Administrator Name Info current and updated Statistical Report Submission- annual Current reported census 21 Casper Reports- CHHA/LTHHCP Only Casper Report- agency adverse events, outcome reports, case mix and OASIS submission statistics and error reports Complete CMS worksheet according to instructions in S&C (Feb 13, 2003) Identifies survey sample and focus areas 22 11

12 Information Analysis: What did I find out? What type of survey is needed? Is there overlap? (LHCSA/TBI) What reg sets will be used? What information needs to be verified during entrance conference? 23 Information Analysis: (cont) What issues need to be addressed on survey? What patient records, home visits, personnel records need to be reviewed/conducted? What survey kits need to be created? What Aspen Survey Event IDs are associated with this survey? 24 12

13 Information Analysis: (cont) Approximately how long will the onsite survey take to complete? How many staff are needed onsite? How should I assign the team? 25 Next steps Conference call will be conducted with each regional office survey team to share presurvey prep findings for a scheduled survey Incorporate archived webinar presentation into regional office training for all new surveyor staff and surveyor staff that did not attend webinar presentation

14 Next steps (cont) Opportunity for regional office staff to provide feedback on pre-survey prep processes and/or worksheet during monthly QA conference calls 27 Questions? 28 14