2019 Year To Date: Colorado Home Care Agencies Top 10 Deficiencies

The year is more than half over. Have you had to face a complaint or renewal survey this year?  Read article for information on surveys conducted from Jan. 1 through July 10, 2019. Click on the link below to view slides showing the Top tags and trends for home health and home care.

2019 Year to Date Top Deficiencies.pptx

The Home & Community Facilities (HCF) Branch of CDPHE has been busy out across Colorado so far in 2019 conducting surveys ranging from initial agency licensure to federal complaint. CDPHE data shows so far this year 38% of all home care agencies in Colorado have been subject to some sort of survey.

How many surveys have been done? What types of surveys? What are the top deficiencies cited? Let’s take a closer look.

There were 243 home care agency (HCA) Surveys conducted between January 1 and July 10, 2019. Surveys, or “inspections” as described in Chapter 26, can take place for many reasons, including initial licensure, renewal, complaint, federal certification, etc..  Additionally, a survey can take place in person at the agency location or over the telephone if CDPHE conducts remotely. In the 243 surveys conducted, HCF issued 706 deficiencies, averaging about 3 tags (2.9) per survey

2019 YTD Total Survey Data (Jan 1. To July 10, 2019)
Total # of Surveys: 243
Total # of Deficiencies Cited: 706
Average # of Deficiencies/Survey: 2.9

Surveys Conducted

Home health agencies had less than half (48%) of all surveys for HCAs this year. In addition to state licensure regulations, home health agencies are subject to CMS regulations for receiving Medicare/Medicaid funds for services. Here are some statistics for Class A home health agencies:

Home Health Surveys
Total # of Surveys: 115
State Re-licensure: 28
State Complaint: 26
Federal Complaint: 23
Federal Recertification: 16
State Re-licesnure/Complaint (combined): 10
State Initial Licensure: 7
Federal Validation: 3
Federal Certification/Complaint (combined): 2

Home care agencies had more surveys than home health, largely driven by the sheer number of home care agencies that go through re-licensure each year. While not receiving Medicare funds (yet), some home care agencies do require Medicaid compliance for receiving Medicaid dollars. Here are the types of surveys conducted for Class B – Home care agencies: 

Home Care Surveys
Total # of Surveys: 128
State Re-licensure: 44
State Certification: 26
State Initial Certification (Medicaid): 18
State Initial Licensure: 15
State Complaint: 14
State Certification Complaint: 6
State Certification/Complaint (combined): 3
State Licensure/Complaint (combined): 2

Deficiencies Cited

With the various types of surveys that are conducted for Colorado home care agencies, there are a dizzying number of tags that can be cited. Surveyors have a list of tags available when conducting a survey and the result can be any combination of hundreds of possible tags.  It is important to know the list of tags and be able to quickly identify the corresponding CDPHE regulation. Below is a helpful guide to the tags available for General (Class A & B), home care and home health agencies.  Additionally, be sure to click on the full list of tags and keep these handy for next time you have survey. 

# of Deficiencies Available for Citation (CDPHE Tag Number)
HCA State General (Apply to Class A & B): 78 (L100-L111, L200-L265)
HCA State Home Care: 55 (L400-L454)
HCA State Home Health: 95 (L300-L394)
Federal CoPs CMS Home Health Tags: 768 (G350-G1078, E0004-E0042)

Do you have the full list of state tags available for citation to surveyors?  Please click below for this important tag list:

HCA General Tag List.pdf

HCA Home Health Tag List.pdf

HCA Home Care Tag List.pdf

Now that we reviewed all the tags that are available for a surveyor, let’s look closer at what tags have been handed out thus far in 2019. As discussed above, there were 706 deficiencies cited from 243 surveys. The pie graph below is a breakdown of the 706 Deficiencies based on the type of agency and regulation.  General applies to regulations for all HCAs (Class A & B), and then Home Health, Home Care and Waiver agency specifics are listed.

With the number of tags possible for a home health agency, it might not be surprising that 40% of all tags were to home health, followed by general tags. But, what might come as a surprise is how many different tags were cited.  There were over 100 different home health tags cited, 44 for Waiver, 42 for General and just 17 for home care.

Top 10 Colorado HCA Overall Survey Tags

#1 General – Personnel Records Content (L246, Ch. 26, 6.11(B))

# 2 General – Personnel Credential Check (L247, Ch. 26, 6.11(C)) 

#3 General – Consumer Record Content – All (L264, Ch. 26, 6.20(A)(1))

#4 Waiver – HCBS Conform to State Standards (L110, Ch. 26, 5.5(E))

#5 General – Quality Management Program (L251, Ch. 26, 6.14))

#6 Non-Medical – Governing Body (L401, Ch. 26, 8.1(B))

#7 General – Discharge Planning (L231, Ch. 26, 6.6(A-B))

#8 Home Health – Medical Orders (L364, Ch. 26, 7.10(A))

#9 Non-Medical – Agency Manager Training ( L405, Ch. 26, 8.3(B))

#10 Non-Medical – Ongoing Training & Documentation (L454, Ch. 26, 8.6(E-F))

Top 10 Colorado HCA Tags 2019 YTD.pdf

For your home care agency, some simple audits and an afternoon or agency review can avoid six of so of these tags.  Have you reviewed your Governing Body information? Does it include all the requirements in 8.1(B)? Have you completed the required the 8-Hour Administrator/Agency Manager course and have the certificate in the personnel file? Do you do quarterly audit of your staff personnel files looking for DORA licenses and requirements in 6.11(B)? 

Scroll to the top of this article to view my slides giving actual 2019 tags cited for each of the Top 10 and the accompanying Plan of Correction submitted by the agency.  Learn from another agency to avoid the tag for yourself.

The top survey is re-licesnure/recertification for both home care and home health agencies.  So, in most cases you know the surveyor is coming. You can usually time your re-licensure survey based off your previous surveys and licensure renewal date. Be sure to flip through the regulations as well as the Top 10 list and then take action for your agency. Most of these tags are ‘low hanging fruit’ and some proactive focus can save you some heartache during survey. 

Need help? Email me at [email protected]. The Business of Senior Care is here for you.