Back for another installment of some common cited deficiencies. There have been a number of home care agencies cited under Deficiency # 456 - Department Oversight - Inspections.
This citation relates to the ability of surveyors to conduct surveys and obtain needed information from home care agencies. CDPHE can conduct a survey as it deems necessary to 'ensure the health, safety and welfare of home care consumers are protected.' This includes both recertification and complaint surveys.
But, when they walk in: how quickly do you have to get them requested documents?
Let's take a look...
From Chapter 26, Section 4.5, here are the rules around inspections:
(a) Consumer records kept in the home or individual consumer documents not included in the HCA's permanent record shall be made available to the Department within two (2) hours of request if the last visit occurred fourteen (14) or more days prior to the request. The time for production may be extended at the Department's discretion.
(b) The consumer file and administrative records, including but not limited to, census and demographic information, complaint and incident reports, meeting minutes, quality assurance, and annual program review documents shall be provided to the inspector commencing within thirty (30) minutes of request. The time for production may be extended at the Department's discretion.
(2) Inspections shall not be conducted in a home care
consumer's home without the consumer's consent.
Does your office have consumer records available when needed?
Here are some quick tips to avoid getting this tag:
#1 - Add this topic to your next QAPI Meeting. With your team, discuss this regulation and the need to have consumer and administrative records available to surveyors timely. Having this as an agenda item for QAPI will show that you are planning a discussion to address this issue.
#2 - Organize your P&Ps. Completing your meetings and documentation is GREAT, but it's only half the battle. You need to be able to find it quickly in survey. This is a great time to organize your major compliance systems into specific binders. Below is my exclusive Colorado home care 9-Program binder system visual. Each of these critical systems is a separate binder and has all the documentation needed for a surveyor.
#3 - Practice, practice, practice. Be ready to go when a surveyor walks in. Practice by walking into your office and asking to see a consumer record, policy or administrative record. See how long it takes. Then look for opportunities to improve!
Still have questions? Email me at [email protected]