Home Health & Hospice Week

Your next Medicare survey could look very different than your last one -- are you ready?

The Centers for Medicare & Medicaid Services put a new home health agency survey protocol in place in May, noted CMS's Pat Sevast at the National Association for Home Care & Hospice's annual meeting in Las Vegas. The protocol is contained in Survey & Certification letter S&C: 11-11- HHA and revised Appendix B of Medicare's State Operations Manual. (Appendix B is "Guidance to Surveyors: Home Health Agencies.")

Revised Appendix B is not actually in the SOM on the CMS website yet, Sevast admitted in her standing-room-only Oct. 3 session. But it's still in effect via the Survey & Cert letter, she assured at the meeting that drew about 5,000 attendees.

Though the new survey protocol has been in effect for six months, many HHAs haven't studied up on it. That could spell big survey trouble when surveyors next come knocking, experts warn.

Learn about these top survey changes that began this year:

• Increased interviews. Expect to see a whole lot more interviews in your next survey, because the new protocol emphasizes questioning staff and patients, Sevast said. "How do you know what the agency is doing" unless you interview employees and patients, she asked.

You can expect surveyors to question everyone from top management down to the person who answers your phone. (For tips on how to prepare for surveyor interviews, see related story, p. 289.)

One conference attendee asked Sevast about interviews with patients with cognitive problems such as dementia. Surveyors must do a record review before conducting a patient interview, so they should be able to see whether a patient is impaired,  Sevast suggested. And HHAs can always offer input to surveyors about patients.

• Fewer record reviews and home visits. The new survey protocol contains some good news for HHAs. Session attendees cheered Sevast's statement that surveyors are now requiring fewer record reviews and home visits (see related chart, this page). Surveyors find the new numbers sufficient to uncover problems at agencies, she indicated.

Also, there's no loophole for big agencies anymore, Sevast explained. HHAs in the highest admissions number category will have to undergo at least 20 record reviews (half with home visits).

• Focus on quality. The new survey protocol directs surveyors to zero in on "specific standards ... most directly related to the delivery of high-quality patient care," Sevast said in her session. CMS is trying to focus more on patient care and lesson paper-based compliance.

Tool: In her presentation, Sevast included a two-page list of home health survey G tags. Surveyors review the green highlighted "Level 1" tags in a standard survey and the yellow highlighted "Level 2" tags in a partial extended survey. For a free copy of the tool, e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "G tags" in the subject line.

The Level 1 standards address nine of the 15 conditions of participation, CMS says in revised Appendix B. "The standards include process standards most closely associated with high-quality patient care and administrative standards most closely related to the agency's ability to deliver highquality patient care," CMS says. "Compliance with these highest priority standards is highly likely to affect care delivery and patient outcomes. If the agency is in compliance with these Level 1 highest priority standards, it is highly likely that the agency is in compliance with all of the CoPs."

Tip: The Level 1 and Level 2 standards are listed on p. 9 of revised Appendix B.

• Lower threshold for citations. Some notso-good news in the new survey protocol is that just "one problematic finding for a Level 1 standard" leads to a "standard-level deficiency citation and a partial extended survey," Sevast explained in her presentation.

"Because the Level 1 highest priority standards are identified as those most related to the delivery of high-quality patient care, a single problematic finding with an actual (or potential) poor outcome(s) ... would support a determination of noncompliance with a standard tag (e.g., one clinical record finding and/or one home visit finding)," CMS explains in revised Appendix B.

It's too early to tell whether this change in protocol is leading to more deficiencies being cited in the field, Sevast said in response to an attendee question.

• Increased surveyor guidance. CMS is providing more guidance to surveyors in areas such as when to expand a survey, when to issue a deficiency, and when to cite a standard-level versus condition-level deficiency. "I hope it will make things clearer," Sevast said.

For example: With standard 484.10 (Patient rights), a surveyor should consider citing the condition when an HHA is out of compliance with G107 (Investigate and document patient complaints and resolutions), G109 (Participate in planning of care and treatment) and one additional tag within that condition (G100 -- G116), CMS says in the protocol.

Note: The survey & cert letter that includes revised Appendix B is at www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter11_11.pdf. Sevast's slides, which include the survey and cert letter, G tag list, and other materials, are at www.nahc.org/Meetings/AM/11/Handouts/309.pdf. CMS training on the new survey protocol is available via a webinar at https://webinar.cms.hhs.gov/hhasurvey.