The Business of Senior Care

Ever been through a home care survey?

The survey and plan of correction process doesn't have to be so confusing and frustrating!

The survey is stressful enough and then it takes forever to put together a plan of correction and not even sure if it will be accepted.   

This guide looks at these main topics: survey & poc process, tips to survive survey, survey timeline and writing a great plan of correction. 

part 2: survey & poc process

Below is a timeline of the survey process. It starts when a surveyor walks in the door and is over when the agency is back in compliance. 

When working on a plan of correction (POC), I have 2 GOALS for you:   

Get the POC accepted the first time.   

Spend the least amount of time on the POC process. (so you can get back to running your business)   

Here's the Survey Timeline: Survey Entrance, Survey Exit, Dept. Issues Findings, Agency Submits POC, Dept Accepts or Denies POC, Agency Submits Compliance Docs, Agency Back in Compliance

We will take a closer look at each step in the survey process!

DID YOU KNOW?

Surveyors can only cite tags from actual regulations! Be sure to find the regulations for your state. Keep these handy to be able to discuss a potential deficiency during survey. 

If you know the reg, you have a better opportunity to talk to a surveyor and save yourself a TAG!

part 3: tips to survive survey

Often the survey started when I would hear this coming from the front desk:  

“Hello, I’m here from the Health Department, I need to speak with the Administrator.”   

I would think, ‘oh no, survey is here.'’  

I’ve gone through surveys for more than a decade and that feeling of anxiousness doesn't go away.

But, I’ve learned some things over the years that have helped to navigate a survey and also get deficiencies dropped. 

Below are the Top 3 tips that helped during a survey: 

#1 Surveyors are good people. Greet them promptly, treat them as a guest, show respect, provide requested information timely and communicate. Doing these things won’t guarantee a deficiency-free survey, but you are more likely to get the benefit of the doubt if in a potential deficiency situation.  

#2 The best time to fix an issue identified by a surveyor is immediately. The second best time is part of the plan of correction. The goal of every survey should be no deficiencies. It takes a considerable amount of time to receive a deficiency, write a POC, wait for it to be accepted, do educations or audits, submit follow up documents, etc. It’s way easier to fix during survey, where once you are aware of an issue you immediately jump into action. Do the staff education, edit the policy, update the client file, etc. Fix what needs fixed. Then, go show the surveyor proof and ask for them to please not issue a deficiency.   

#3 Only give information that is specifically requested. To be most efficient of everyone's time, just provide what is being asked for. If it doesn’t help support the specific issue at hand, don’t bring it up.  

After the surveyor has exited with you, you should have a good idea of the deficiencies being cited. Next we’ll talk about key timelines while you are awaiting your results from the health department.  

Also, I put together some additional survey tips that I've learned over the years. 

Tips to Navigate Survey

part 4: crazy surveys

If you've been in healthcare long enough (doesn't seem like much time is required at all these days!), you have most likely experienced some crazy things during the survey process. The good news is that your are not alone. The unique experience of survey is a shared one with many home care agencies across the country. 

part 5: survey timeline

Staying in compliance with the health department is THE PRIORITY when going through the survey process.  

As long as you’re in compliance while going through the survey and plan of correction, you’re doing great. 

Knowing due dates and required documentation to submit is critical to staying in compliance. Below we discuss each part of the survey process. 

(1)  Survey Entrance - the survey process starts with the survey entrance. Survey entrance typically happens when the surveyor walks in the door at your agency to initiate either a recertification or complaint survey. A survey can also start with a phone call to the agency for a 'eComplaint', which is the same as an in-person survey, but takes place remotely.  

(2) Survey Exit - the first part of the survey process, the actual survey, is completed with the survey exit. For an in-person survey, the surveyor will typically ask to meet with the Administrator to review the 'areas of concern' or 'initial findings'. If the Administrator doesn't know what the surveyor has been reviewing, they will now with the exit. If there are no areas of concern and no potential deficiencies, this is where the survey process stops! If not, the surveyor still has time after exit to decide whether to purse citations and the agency won't know for sure until the next step. 

(3) Dept. Issues Findings - after survey exit, the Health Department has 10 BUSINESS days to review survey documentation and issue a "Statement of Deficiencies". The agency will receive a notification through the online portal and must log on and review the deficiencies. Deficiencies are listed on a standardized form that is borrowed from CMS (Medicaid and Medicaid) know as the 2567. The deficiency number is listed at the left, then a summary of the specific findings, then the agency Plan of Correction (POC) will be listed next to the citation, and the completion date to the far right.

Here's an example of a 'Statement of Deficiencies'. 

(4) Agency Submits POC - after the agency receives the Statement of Deficiencies, the agency needs to develop and submit a Plan of Correction (POC). The agency has 10 CALENDAR days to submit a plan of correction through the portal that contains the five required plan of correction elements for EACH tag. (Here are the 5 elements required.) 

Notice the difference between business days and calendar days. Business days are any days that the Health Department is open, typically Monday through Friday, except for any recognized holidays. For calendar days, it is all the dates on the calendar, including weekends and holidays. How nice right? 

When you receive notification of the Statement of Deficiencies, I would always look at the letter discussing the survey first. It is addressed to the Administrator and has 3 main components: agency was issued deficiencies, plan of correction due date, agency can file informal dispute resolution (IDR). 

BE SURE to check the due date for the plan of correction. This is the most important date! And it may not line up with the regulation of 10 calendar days. 

(5) Dept. Accepts or Denies POC - once the POC is submitted to the Department, it will next be reviewed by someone at the Department and they will determine if they accept or reject the POC. If accepted, then the agency moves to the next step. If it is rejected, the Department will respond with what needs to be fixed in the POC. Typically, the POC doesn't directly address the deficiency that was cited and needs to be updated to fix what was found to be broken.

(6) Agency Submits Compliance Doc - after the POC is accepted, the survey process is not quite over. When the POC is accepted, the Department will then provide a deadline to submit documentation from the POC. This step is in place so the Department can review actual documents completed showing that the agency is doing the work to fix the deficiency. 

(7) Agency Back in Compliance - last, the Department will put the agency back in compliance. The Department will review the compliance documents and if the documents show what was promised to be done in the POC, then the Department puts the agency 'back in compliance'. This means the survey process is over and the agency can continue normal operations under their home care license. The goal of the entire survey process is to go from 'out of compliance' once deficiencies have been issue to 'back in compliance' at the end of the process!  

part 6: writing a plan of correction (POC)

POC BINDER!

The first thing I always do after the survey exit is to make a plan of correction (POC) binder. This binder will contain all of the documentation needed for the plan of correction.  

Tip: It’s true, at this point you don’t know for sure if your agency will be issued any deficiencies. It’s also possible deficiencies will be added or deleted. But, by creating this binder now you will help your future self a couple of ways:  

1) keeping all needed documents in a binder so you don’t misplace them and have to recreate them later and 

2) once organized you can create a plan of correction and start checking off completed items and have a place for the documentation in the binder as you go! 

Goal of the POC binder: to organize POC documentation needed to submit to CDPHE in order to get back into compliance and move on with your life.  

I’ve found spending a little extra time here in organizing a binder, saved me countless hours and stress when it came time to submit the compliance documentation to the health department.  

A POC Binder is straightforward to make and after you do it a few times, sadly you’ll be able to do it in your sleep. 

Just need a 3 ring binder (preferably 2” binder) and a couple of 5 tab divider packs.  

Here’s a template for a Table of Contents for the Binder.  

Also, here's a template for writing your own Plan of Correction. 

After survey, I would start putting in documents like staff member education, completed audit or copy of a consumer grievance that was done during the survey. Then as I completed items on the plan of correction, I would put them in the binder.  

5 elements of an AWESOME plan of correction!

I’ve worked with numerous agencies on writing a plan of correction for a complaint or recertification survey.  

The key to writing a plan of correction is including the five required elements for each tag while NOT committing yourself to unnecessary work. Meaning, don’t commit yourself to completing an audit of ALL client files when doing an audit of 5 client files is acceptable. Or don’t say you will provide education to ALL caregivers if an issue was identified for only one caregiver.  

Don’t create more work for yourself! 

Completing a plan of correction is enough work already.  

We will look at some actual examples of writing a plan of correction to help demonstrate. Next, let’s look at the 5 elements required for a POC. In my online course on writing a plan of correction, we break these elements down even further.  

5 elements required for POC:

 (Click here for download)   

#1 - The plan for correcting the specific deficiency. The plan should address the internal processes that led to the deficient practice cited. 

If the deficient practice was cited for a specific client(s) or staff, the description shall include the measures that will be put in place or systemic changes made to ensure the deficient practice will not reoccur for the affected client(s)/staff and/or other clients/staff having the potential to be affected. 

#2 - The procedure for implementing the acceptable PoC for the specific deficiencies cited. 

#3 - The monitoring procedure to ensure the PoC is effective and the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements. 

The monitoring plan must identify all of the following:  

    a. Exactly how and what will be reviewed as part of the monitoring; 

    b. The sample, representative of the agency/facility census, included in the monitoring;  

    c. How often the monitoring will occur;

    d. How the monitoring will be documented;

    e. The total minimum length of time the monitoring will continue (a minimum of 3 months is required); and

    f. How the monitoring will be included in the QAPI process.

#4 - The title of the person responsible for implementing the acceptable plan of correction. 

#5 – The completion Date. 

Provide the date when corrective action will be completed for the deficiency cited. When ongoing monitoring or other activity is part of the plan, the completion date would be when the first cycle is completed and the corrective action has been applied to all active patients/clients/residents having the potential to be effected by the deficient practice. The date should not be later than 30 days following the survey exit date. 

Below is an example of a completed Plan of Correction from an actual deficiency received by a home care agency this year. 

Be sure to download the easy-to-use templates to make writing a POC stress-free!!

Plan of Correction Example

Survey Exit Date: 12/2/22

CDPHE Due Date to Send Statement of Deficiencies (10 Business Days): 12/16/22

POC Submission Due Date (10 Calendar Days): 12/26/22

POC Compliance Date listed in CDPHE Survey Letter: 12/31/22

Deficiency #: Home Care-Tag 415

Deficiency Topic: PCW Documentation

Regulation: Documentation shall contain services provided, date and time in and out, and a confirmation that care was provided. Such confirmation shall be according to agency policy. 

Survey findings: Based on record review and interview, the agency failed to ensure written service notes documenting the services provided by staff (PCW #2) at each visit were maintained and available for review for 1 of 3 records reviewed (Consumer #1).

#1 - The plan for correcting the specific deficiency. The plan should address the internal processes that led to the deficient practice cited.

PCW #2 provided education on agency policy to record written service notes documenting the services provided by staff at each visit at the time of survey on 12/2/22. 

#2 - The procedure for implementing the acceptable PoC for the specific deficiencies cited.

Agency reviewed Consumer #1 care plan and service notes to ensure caregivers are recording written service notes documenting the services provided at each visit by 12/26/22. 

#3 - The monitoring procedure to ensure the PoC is effective and the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements.

Agency will use an audit tool starting 12/27/22 to review two clients per week for 3 months to ensure caregivers are recording written service notes documenting the services provided at each visit. All monitoring Quarterly will be reported to Quality Management Program for reviews and conclusions.

#4 - The title of the person responsible for implementing the acceptable plan of correction.

Administrator or designee

#5 – The completion Date.

12/31/22

That's it! Hopefully this gives you insight into the Survey & POC process. Now you'll be ready to dominate survey! 

Download my free eBook, with BONUS - 5 POCs from the Top 5 Home Care Tags!

Guide to Home Care Survey & Getting Your Plan of Correction ACCEPTED!

Need more detailed examples of writing actual POCs? Check out my Online Course: 

How To Write a KICK-ASS Plan of Correction

Want some 1-on-1 help for survey or plan of correction? 

Contact me at 303-578-8262 or [email protected]

I can help write a custom POC to help get you back in compliance ASAP!