SURVEY UPDATES AND SUCCESSFUL PLANS OF CORRECTION

3/22/2021

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Patricia W. Tulloch RN, BSN, MSN, HCS-D

Senior Consultant

[email protected]

845-889-8128

COMPLIANCE READINESSSURVEY UPDATES AND

SUCCESSFUL PLANS OF CORRECTION

PROGRAM GOALS

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➢ Identify recent New York State survey trends for

Licensed Home Care Providers.

➢ Discuss recent updates in Plans of Correction to

address common and complex survey deficiencies.

➢ Discuss tips and tools to support survey readiness and

plan of correction success.

➢ Quick Reference Take Aways

Updated New York State Survey Request Document

Updated New York State Infection Control Survey Tool

Sample EPOC Policy & Procedure

Perform a Self-Assessment. Are You Ready for Survey?

Mitigate Your POC with Survey Readiness

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mailto:[email protected]

3/22/2021

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PROGRAM NOTES

This information is intended for informational

purposes only and is updated for information up to

March 23, 2021.

Note that CMS, CDC, the New York State

Department of Health, New York State Medicaid and

all regulatory bodies update official information on a

regular basis during this Public Health Emergency.

Please reference the resources listed on the last slides

to continue to track and update on all relevant

provider developments on this topic.

This information is not intended to render medical,

legal, financial, accounting or other professional

advice. Seek expert relevant assistance as needed.3

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WHY SURVEYS?

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➢ Ensure Compliance

New York State Regulations & Standards

Surveyors Now Required to Report if Suspected

Fraud

➢ Investigate Reported Complaints

Increase in Home Care Complaints

➢ Surveillance of High Risk Areas for HC Providers

Qualified HHA’s & PCA’s

Supervision of All Paraprofessional Staff

Complete Physician Orders

Documentation of All Care & Services

Complaint and Quality Standards

Regulatory Oversight for New & Updated

Regulations

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NYS OMIG

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o NYS Medicaid Spending = $76 Billion in 2020

o New York State Office of Medicaid Inspector

General (OMIG)

Provides a Roadmap for Audit Priorities

Goals

➢Enhance compliance

➢Fight fraud & abuse

➢Use analytics (data mining)

o Home Care Providers

Use of a Verification Organization (VO); EVV

Recover Duplicative Claims (Billing)

Wage Parity & Minimum Wage Compliance

OMIG ON HOME CARE

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➢ Ensure Personal Care Services

✓ Are provided based on a comprehensive

assessment

✓ Are provided with written orders from a

qualifying practitioner

✓ Are provided with a written aide plan of care

✓ Are provided under the authorization of LDSS,

when indicated

✓ Ensure billing matches care and services provided

by the LHCSA

➢ Ensure Private Duty Nursing Services

✓ Are provided according to physician orders

✓ Ensure billing matches care and services provided

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BOTTOM LINE

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✓ Updated Policies, Procedures & Practices

✓ Updated Personnel & Physical Files

✓ Orientation & Supervision of Professional &

Aide Staff

✓ Updated & Accurate Clinical & Billing Files

✓ Accurate & Timely Tracking of Missing

Documentation

✓ Documentation to Support all Required

Regulatory & Billing Standards

➢ Proactively Mitigate High Risk Issues

✓ Internal Compliance Audits

➢ Know Your Contracts

✓ Agency’s Responsibilities for Each Agency

Contract

REGULATIONS & STANDARDS

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➢ Conditions of Participation: CoP’sCode of Federal RegulationsChapter 4: Section 484.4: HHA Training; Competency; Supervision

➢ New York State Home Care Regulatory StandardsTitle 10: Article 36: Sections 765 & 766State Operating Manuals and Interpretive Guidelines

➢ New York State Specific Practice Acts Nurse & Therapy State Practice ActsHome Health Aide & Personal Care Aide Practice Guidelines

➢ OSHA RegulationsCOVID-19 Directives & Reporting

➢ New York State Medicaid Claims Processing ManualOMIG Compliance RequirementsNew York State Billing Requirements

➢ Oversight Contractors: MCO’s & MLTC’sContract Responsibilities for Provider Participants

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LHCSA STANDARDS

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➢ 766.1 Patient Rights

➢ 766.2 Patient Service Policies and

Procedures

➢ 766.3 Plan of Care

➢ 766.4 Medical Orders

➢ 766.5 Clinical Supervision

➢ 766.6 Patient Care Records

➢ 766.9 Governing Authority

➢ 766.10 Contracts

➢ 766.11 Personnel

➢ 766.12 Records and Reports

NEW ERA: SURVEY UPDATES

➢ Centers for Medicare & Medicaid (CMS)

Issues Updated Survey Guidance (12/20)

Focused Surveys for Infection Control in All

Healthcare Settings

➢ New York State DALs

Waivers

Waivers Suspended

Other Updates

➢ Home Care Infection Control Surveys: OSHA

COVID-19 Policies

PPE Reserve & Burn Rate

➢ Goals: Mitigate Transmission of COVID-19

Protect Communities and Workforce10

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SURVEY TRENDS

➢ Return to On Site Surveys

➢ Survey Request Document Updates (Reference Tools)

➢ Off Site Surveillance

➢ Rosters: HCR & CHRC

➢ Policies & Procedures

➢ Updates with DALs

➢ Infection Control, Infection Control, Infection Control

➢ Emergency Preparedness

➢ Staff Call Down Lists

➢ Community Partner Lists

➢ Other Considerations11

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SURVEY DOCUMENT REQUEST➢ Arrival Protocol: Check Credentials; COVID-19 Screen; Other

➢ LHCSA Survey Document/Information Required✓ Current Patient Census & Active Roster

✓ Visit Schedule

✓ Personnel Roster

✓ List of Discharged Patients within last 3 months

✓ Space for Surveyors

✓ Name of Owner/Operator

✓ Name of Agency Responsible RN

✓ Organizational Chart

✓ Admission Packet

✓ Policy Manual: Flag All Policies Requested

✓ Complaint/Grievance Log

✓ EDP

✓ QI Committee Minutes for Past 12 months

✓ Governing Authority Meeting Minutes past 12 months

✓ Copy of DOH Approved Management Agreement, if applicable

✓ Orientation to Records

➢ Specific Policies & Other Documents 12

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MORE ON NEW YORK

STATE SURVEYS REQUESTS

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➢ NYS DOH Document Request

Clinical Supervision Policy

Criminal History Record Check

Home Care Registry

Complaint Policy

Influenza Vaccination/Flu Mask Requirement

Health Commerce System

Emergency Preparedness Plan

➢ Staff Call Down List

➢ Community Partner List

➢ COVID-19 Policies

➢ Policy Updates Since Last Survey

MORE ON NEW YORK

STATE SURVEYS REQUESTS

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➢ COVID-19 Policies

Policy for Daily Screening of Staff

Policy/Protocol for Staff Returning to Work Following COVID-19 Exposure or Infection

Policy/Protocol for Screening Patients for COVID-19 Symptoms Prior to Accepting New Admissions & Referrals

Records for Infection Control Training Conducted in the Past 45 Days to Include Staff Trained in the Content of the Training

Staffing Plan for COVID-19 Positive or Suspected Patients (PUI)

A Copy of Care Plan for Two COVID-19 Positive Patients You are Currently Caring For

➢ Do You Have Documentation of Screens?

➢ Process if Staff Positive Screen?

➢ PPE: Storage; Distribution; Protection; Cleaning

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INFECTION CONTROL

TRAINING

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Survey Documents Needed

COVID-19 & Infection Control Education for All Staff

Staff Education Records

Infection Control Education Materials

Considerations

COVID-19 Updates

COVID-19 Policy & Protocol Updates

Infection Control Updates

Emergency Preparedness Updates

Ensure All Staff are Updated

Prepare For Audit Updates

STAFF DEMONSTRATE

USE OF PPE

Trained in donning and doffing, cleaning

Accessing PPE

What type will you use? N95s, surgical masks, cloth

masks, homemade masks

Re-use of PPE

Disinfecting PPE

Transporting PPE

Delivering

Storage

Monitoring16

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SOD & EPOC BASICS

➢ NYS DOH will Communicate Via Email

✓ Survey Results

✓ Acceptance or rejections

➢ Access to EPOC Governed by HCS Roles

➢ Only Person to Sign the Attestation and Submit the

EPOC is the Administrator

➢ Once Submitted: No Further Changes Can be Made

➢ Each Tag May be Submitted Individually

➢ EPOC with Watermark Indicates the Plan has Not

Yet Been Accepted

➢ Check HCS Twice a Day for Communication

➢ Keep a Hard Copy in Administrator’s Office 17

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EPOC

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MORE ON EPOC

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SUCCESSFUL EPOCS➢ Timely, Specific to Deficiency

➢ Plan Should Address the Processes that Lead to the Deficiency Cited

➢ Meets All Requirements (CMS: June 16, 2017)

✓ What corrective action(s) will be accomplished for these patients found to be affected by the deficit practice

✓ What measures will be put in place or systemic changes will you make to ensure that deficient practice does not recur

✓ How will the corrective action(s) be monitored to ensure the deficient practice will not occur, including target compliance goals that will indicate effectiveness or corrective actions and what steps will be taken if the target goals are not met.

✓ Target Date

✓ Responsible Person20

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COMMON SODS & POCS

➢ W606: Home Care Registry (HCR)

➢ R610: Submitting Requests for CHRC

➢ W614: Criminal Background Record Check

(CHRC)

➢ H 402: 766.3 Plan of Care

➢ H502: 766.4 Medical Orders

➢ H622: 766.5 Clinical Supervision

➢ H722: 766.6 Patient Care Record

➢ H1006: 766.9 (c) Emergency Preparedness

Plan 21

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HCR: POCS

➢ W606: Home Care Registry (HCR)Not Updated To Personnel Roster

Does Not Match CHRC Roster

➢ POC Elements✓ Update Policy & Procedure

✓ Educate Staff (Keep Records of Inservices)

✓ Authorized staff will enter the aide’s information into the HCR for all active aides

✓ Copy placed in aide’s personnel file

➢ Monitor Progress✓ Audit 100% personnel records current staff

✓ Continue monthly audits until 100% for 3 months

✓ Audit 20% personnel records of existing and terminated staff

➢ Quarterly CQI Meetings: Results Reported 22

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CHRC: POCS

➢ R 722 CHRC Process

Not Updated To Match Personnel & HCR Roster

Employees with Pending Determination Reports: Weekly Supervision

➢ POC Elements✓ Update Policy & Procedure

✓ Educate Staff (Keep Records of All Inservices)

✓ Pending CHRC Roster Reviewed Weekly: Tracked & Reported

✓ Weekly Supervision for Temporary Employees

➢ Monitor Progress✓ Audit 100% personnel records new staff for weekly supervisions

✓ Continue monthly audits until 100% compliance for 3 months

✓ Continue 20% quarterly audits for CQI

➢ Responsible Person; Completion Date23

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HCR & CHRC POLICY & PROCESSES

➢ HCR

Is the DOH HCS Account & Roles Up to Date?

Does the policy reflect personnel role changes as soon as they occur

and at a minimum on a monthly basis?

Is the HCR updated for new employees & terminations within 10

days?

➢ CHRC

Policy reflect 2 CHRC Authorized Persons (APs)?

Is your Policy updated with termination timeframes?

Supervision of temporary personnel (weekly supervisions)?

Procedures for Hold-in-Abeyance, Pending Denials and Final

Determination letters?

Reporting terminations & separations (no later than 30 days)?

➢ Check the NYS DOH Updated CHRC Surveillance Protocol

High Risk Agency Process: OMIG Priority24

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PLAN OF CARE: EPOCS

➢ H408 & 766.3(d) Plan of CareLate assessments/re-assessments

Plan of Care not updated with patient changes

➢ POC Elements✓ Update Policies & Procedures

✓ Educate Staff on Revised Policies (Document All Inservices)

✓ Home visits to all surveyed patients to re-assess & ensure up to date Plans of Care

➢ Monitor Progress✓ Audit 100% clinical records to identify other patients who

did not have re-assessments q6months. Update Plans of Care.

✓ Audit 20% current patient records monthly until 100% compliance


➢ Responsible Person; Completion Date 25

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CLINICAL SUPERVISION: POCS

➢ H 622 766.5 (c) Clinical SupervisionLate Aide Orientation and/or Supervisory Visits

Aide Plan of Care not updated with patient changes



✓ Home visits to all surveyed patients to re-assess & ensure up to date Plan of Care and Aide Supervision

➢ Monitor Progress✓ Audit 100% clinical records to identify other patients who

did not have timely supervisions. Aide Plan of Care Updates

✓ Audit 20% current patient records monthly until 100% compliance



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CLINICAL SUPERVISION

PROCESSES

➢ Process Considerations

✓ Supervisory RN Review Caseloads with Field RNs

✓ Schedule Updates

✓ Admission Planning

✓ Timely Re-assessments

✓ Timely Aide Supervisions

➢ Documentation Oversight

✓ New Nurses

✓ Nurses with Inconsistent Clinical

Practices/Documentation

➢ Staffing Challenges

➢ COVID-19 Remote Service Practices 27

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OTHER COMMON SODS

➢ Physician Plans of Care (766.3; 766.4)

Incomplete (Medications; Service Delivery)

✓ Meds: Need frequency, form, dose, route

✓ PRN Meds: Reason for PRN Medications; MDD

✓ Meds: Oxygen: dose, liter flow, delivery system

Not Updated with Patient Changes

➢ Aide Plans of Care (766.5)

Not Individualized to Specific Patient Needs

Not Updated with Patient Changes

➢ Aide Duty Sheets (766.5(b))

Not Consistent with Plan of Care

Scope of Practice

Agency Notifications 28

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PATIENT DISCHARGES: POCS

➢ H 324 766.2 (a) (9) Patient Services P&Ps

Practitioner(s) not notified on timely basis for patient discharges

Incomplete Discharge Summaries



Notification no less than 48 hours prior to discharge

✓ Revise required clinical documentation for discharge summary

➢ Monitor Progress✓ Audit 100% of discharged patients monthly until 100%

compliance for 3 months

✓ Continue 20% quarterly audits discharge files for CQI

➢ Responsible Person; Completion Date29

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OTHER COMMON SODS

➢ Written Emergency Preparedness Plan (H1006)

Lacks identification of types of emergencies;

Current patient roster does not include all required

EP elements;

Procedure not available for patient’s who refuse to

evacuate when ordered evacuation;

Procedure for alternate communication if telephone

and/or computers are disabled;

Lack of updated contact list for community partners;

Lack of updated staff call down list.

➢ Reference NYS DAL

Emergency Preparedness Requirements for Home Care 30

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OTHER COMMON SODS

Specific Agency Ongoing EP Requirements

Patient Roster with All required elements

Patient name & address

Classification Level

TAL

Caregiver Name & contact number

Specific care needs

Other data for first-responders

Current EPD Staff Call Down List

Current Community Partner Contact List

Plan & Policies

Identifies how the agency keeps all information updated

Identifies who keeps the information updated for each31

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EDP: POCS

➢ H 1006 766.9 (c) Governing Authority

Lack of updated EDP Plan & Policies (Reference DAL)

Lack of Updated EDP Documentation

➢ POC Elements✓ Update Policies & Procedures; Plan


✓ HCS Log ins daily with distribution of updates

➢ Monitor Progress✓ Document HCS Log Ins

✓ Audit HCS Logs for daily log ins until 100% compliance for 3 months

✓ Continue 20% quarterly HCS log audits for CQI

✓ Participate in DOH EDP Drills: Maintain HERDS & Report to CQI


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EPOC DOCUMENTATION

➢ Quality Committee Meeting Minutes

✓ Add POC Category for CQI

✓ Track and Trend POC Outcomes to Meet 100% x 3

months

✓ Continue to Report POC Compliance Items per EPOC

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MORE ON POC QUALITY MONITORING

PERSONNEL & HEALTH RECORDS COMPLIANCE

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LHCSA TELEHEALTH DOCUMENTATION

➢ Virtual Visit Documentation Requirements

Must have physician orders for virtual visits

Specific documentation in each clinical record for each virtual visit as to the remote technology used

Start and end times of each call

Specific care delivery, instructions, supervision documentation

Clinician signature & date on each virtual visit

➢ Ensure Nursing Staff

Update all physician orders to include virtual visits for aide supervision

Update Aide Plans of Care and document each virtual visit

Document specific Aide supervision & Aide understanding regarding Aide Plan of Care updates

Do the Patient/Family/Caregiver understand the Plan of Care

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ADDITIONAL DOCUMENTATION NEEDS

➢ Personnel Files

Document remote completion of the personnel health

assessment & TB Risk Assessment Questionnaire

Indicate remote review of all personnel requirements with

newly hired staff

Document delivery and receipt of all required personnel

elements

Ensure daily screening of each employee for COVID-19

required elements

➢ Inservice Updates

Ensure documentation includes time for Q & As on all

orientation and inservice updates

➢ Documentation Oversight36

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CONSIDER NOW

➢ Proactively Prepare for Survey Now

Updated Policies & Procedures

COVID-19 Policies & Protocol Updates

Staff Education Updates: Infection Control & PPE

➢ Ongoing Compliance Oversight

Streamline and/or Focus Quality Initiatives

Focus on Priority Compliance Issues

Benchmark; Track & Trend

➢ Staff Support

Feedback on Current Updates & Practice Changes

Clear Communication Requirements

Safety & Quality Focus 37

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RESOURCES

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www.cms.gov/Medicare/Medicare-GeneralInformation/

Centers for Medicare & Medicaid Services

State Survey Agency Directors

Reference: QSO-20-21-NLTC (Revised 12/30/20)

https://coronavirus.health.ny.gov/home

NYS DOH COVID-19 Webpage

NYS COVID-19 Guidance for Home Care Agencies & Hospice Providers

www.cdc.gov/coronavirus/2019-ncov/

CDC COVID-19 Provider Guidance

CDC COVID-19 Consumer Guidance

https://www1.nyc.gov/site/doh/covid/covid-19-main.page

NY City Health COVID-19 Web Site

Comprehensive Guidance & Resources for COVID-19 Updates for NYC

www.rbclimited.com

Provider Resources & Expert Plan of Correction Services

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https://coronavirus.health.ny.gov/home

https://www1.nyc.gov/site/doh/covid/covid-19-main.page

SURVEY UPDATES AND SUCCESSFUL PLANS OF CORRECTION

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