What to expect during a survey

What is a survey

A survey can be conducted by The California Department of Public Health (CDPH) or an accrediting body (The Joint Commission (TJC previously JCAHO) or Accreditation Commission for Health Care (ACHC)) to confirm an agency is practicing in accordance with state and federal guidelines.  Many things are reviewed during a survey, with a majority of the survey consisting of records reviews.  For instance, an agency must have an office fire escape plan, emergency readiness assessment for local risks, all credentials for clinicians must be up-to-date if they are visiting patients, and patient records must comply with the agency policies and procedures such as obtaining physician signatures for all care plans within 30 days.  A full list of ACHC expectations is attached to this email to provide an idea of what an agency is preparing during a survey.  You will notice that the vast majority of this does not apply to you.   

What do clinicians need to know during a survey

So much of a survey happens behind the scenes, in the office, and is the responsibility of the HR and Administrative teams.  But, one portion of the survey requires that the surveyor ensure proper care is being provided in the home.  During this, the surveyor does not judge the therapy you are providing, but rather makes sure that you are following state and federal guidelines, in addition to agency policies and procedures.  The surveyor is not there to trick you, challenge you, or take away your license.  They are only there to ensure patients are receiving care in accordance with state, federal, and agency policies and procedures. Everything the surveyor expects of you is something you should already be doing, so don't worry!

What needs to happen in the home (start to finish)

• Introduce yourself or say hello to the patient. Identify them using two forms of identification, such as name and date of birth to ensure you are speaking to the correct patient. 

• Ask if there is a good place for you to put your things down.  This should be a flat, raised surface such as a counter top or table top.

• Before placing your therapy bag down, put down your disposable chuck/protective  barrier such as wax paper or puppy pads.

• Before reaching into the bag, you must wash or sanitize your hands. You may use alcohol based hand sanitizer or wash your hands with liquid soap and paper towels that you have brought along, asking the patient to use their sink.  If you wash your hands with soap and water, scrub for at least 20 seconds and turn off the faucet with the paper towel you used to dry your hands with.

• Now that you have clean and sanitized hands, you can assess the patient's vitals.  

• If the patient's vitals are outside of parameters, including a pain level of 8 or higher, you must report this to the agency and ensure they have contacted to the physician while you are with the patient. This should be noted in the patient's medical record. 

• After taking the patient's vitals, you may perform the interview portion of the visit.  Confirm the patient has not had any changes to their medications, has not been hospitalized, has not changed their insurance.  Discuss the patient's complaints, condition, and desires/goals for your home health therapy discipline.

• Before returning any equipment to the bag, sanitize your hands and wipe down the equipment with a cleansing wipe such as Lysol or Clorox wipes.  You may place soiled equipment on a disposable chuck/barrier rather than sanitizing it immediately.    

• Assess the patient and provide treatment as usual.  If you will be conducting any activities such as observing wounds, touching soiled laundry, or cleaning up spills, you should wash or sanitize your hands and then donn a pair of gloves before the activity.  After the activity, doff the gloves and wash your hands.  

• Ensure that the patient is kept updated with your observations of their medical needs and the orders you will be placing for them.  If you will be ordering additional care for your discipline, this should be made known to the patient. 

• Signing in to the home health record is another important aspect of patient involvement in care.  Leave your name and phone number and sign in to the home health folder.  This should be done in conjunction with obtaining the patient's signature for the treatment session. 

• Sanitize any additional equipment that has been used, such as pens and styluses.

• Gather any trash and put it into your disposable trash bag to be thrown away off site. Do not place this trash in your clean therapy bag.   

• Before leaving the patient's home, just as you would 'scrub in, scrub out' in the hospital, you must wash or sanitize your hands.  

Common questions and answers

A surveyor may casually ask you about agency policies and procedures at some point during the visit, especially if you are conducting an SOC.  These P&Ps are largely set by state and federal guidelines, as well as by the accrediting bodies, so you can confidently answer the following regardless of the agency:

Q:  How are patients informed about their Rights and Responsibilities?

A:   All patients are provided this information during admission to home health, along with a written copy in their home health patient information booklet. 

Q: How do we ensure the patient is informed about an Advance Health Care
Directive?

A: All patients are asked if they have Advance Directives during admission and copies are both obtained and kept in the medical record.  Social workers are available if patients require assistance making an Advance Directive. 

Q: When you have a patient who does not speak the same language, how do you
communicate?

A: Agencies always make an effort to staff patients with a clinician who natively speaks the same language.  If this is not possible, such as for an uncommon language or hearing impaired patient, the agency maintains a translation line which also provides video translation (IE ASL) as needed.

Q: What is the procedure for reporting abuse/suspected abuse?

A: Every clinician is a mandated reporter.  Known or suspected abuse is to be immediately reported to APS as well as to the Clinical Manager. 

Q: How often and how is pain measured?

A: Pain is measured during admission and during each visit.  1-10 or the faces scale is used to assess pain levels, while clinicians also assess location, quality, radiation, score, and timing of pain. 

Q: How is home safety evaluated?

A: Home safety assessments include fire hazards, oxygen safety, fire exits, bathroom safety, and environmental safety(fall risks) such as safe equipment storage and movement within the home. 

Q: What measures does the agency assess for improvement?

A: Infection control, falls prevention, wound reduction. 

Q: What qualifies a patient for home health?

A: Being confined to the home, under the care of a physician, receiving services under a plan of care that is reviewed by a physician, and being in need of skilled services such as nursing, physical therapy, speech therapy, and/or occupational therapy. 

What happens if mistakes are made during a survey

Mistakes are classified according to the harm that they will cause to a patient.  If many, especially egregious mistakes are made, the agency may lose their license to practice.  More often, however, mistakes are resolvable via a Plan of Correction, which the agency must establish to demonstrate their commitment to preventing these things in the future.  If a mistake is made in the moment and you recognize this, simply fix it then and there!  For instance, if you turn the faucet off with your clean hands, re-wash your hands and turn the faucet off properly, using a paper towel! Surveyors want to know that you know the proper procedure and that you are making an effort to follow this.    

Additional Materials

• Hand Washing Video

• Bag Technique Video

• SOM_APPENDIX_B_FOR_HHA.pdf is the State Operations Manual Appendix B - Guidance to Surveyors for Home Health Agencies. When in doubt, go straight to the source.  This is exactly what a surveyor will look for. 

• California Code Health and Safety Code Chapter 8. Home Health Agencies is the entire, current expectation that the state of California maintains for home health agencies.  Typically these are rather vague and are already captured within federal guidelines, as the expectations for home health care remain quite consistent across the nation. 

• As mentioned above, Items Needed for Survey - HH.pdf is a checklist of items agencies must prepare for survey. It is not relevant to what a surveyor would assess in the field and is only so that you understand a survey consists of many pieces aside from home visits.