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[Part 1] Is Your Agency Survey-Ready? Reviewing Common Deficiencies on the CoPs


    For a time, the Centers for Medicare & Medicaid Services (CMS) suspended certain surveys and routine inspections, and temporarily froze survey data in 2020 in response to the COVID-19 pandemic. Along with this pause was the prioritization of infection control and immediate jeopardy situations to allow healthcare providers and suppliers the time they needed to respond to the health crisis.  

    The change was in effect until mid-August 2020 when normal survey activity was resumed. This temporary modification had an impact on the weighting of survey data, which was held constant until January 2021 when CMS resumed analyzing results from surveys prior to the temporary suspension.

    Now that surveys are starting to pick up again, let’s review some compliance concerns in relation to the Conditions of Participation (CoPs) and how to address them.


    The Challenge

    The CoPs focus on a patient-centered, data-driven, and outcome-oriented model of care. This approach has added standards regarding patient rights and clinical conditions that encourage patients’ participation in the administration of care at a much higher level. It is oftentimes a challenge for agencies to implement, monitor, and/or comply with these standards as it relies heavily on the field clinicians’ assessment and documentation skills.

    Considering this hovering challenge, agencies must provide ongoing education to clinicians, make home supervisory visits, and audit in an ongoing manner via quality assessment and performance improvement (QAPI) to ensure compliance with the CoPs.



    Before proceeding with the resolution, it is important to first understand the level of deficiencies classified under the CoPs:

    1. Standard-level deficiency – This means noncompliance with one or more of the standards that make up each condition. It is nearly impossible to avoid receiving any standard deficiencies during a survey. A Plan of Correction must be written by the agency to be approved by the regulatory body.
    2. Condition-level deficiency – This is issued if a surveyor determines that an agency is not in compliance with a condition, such as not having a formal agency-wide QAPI program. Multiple standard-level deficiencies may also account for a condition-level deficiency citation. Failure to clear a condition-level deficiency can affect an agency’s Medicare certification because it may indicate that the agency is not able to render adequate care or that it adversely affects patient health or safety.
    3. Immediate jeopardy – This refers to a situation in which the provider’s noncompliance with one or more requirements of the CoPs has caused or is likely to cause serious injury, harm, impairment, or death. A follow-up survey will typically be conducted within seven (7) to 21 days and the survey will have to show that the deficient findings have been corrected. Immediate jeopardy is often cited for potential harm to a patient. If there is no immediate compliance from the agency—which usually involves policy and/or process change, education, and performance improvement projects—CMS can terminate their Medicare certification. 
    Frequent Deficiencies include:

    G590 Promptly Alert Relevant Physician of Changes
    G574 Components of POC
    G536 POC Includes Review of Current Medications
    G710 Services to be Provided in Accordance With POC
    G608 Services Are Coordinated to Meet Patient Needs
    G716 Clinical Notes
    G682 Precautions to Prevent Transmission of Infections and Communicable Diseases
    G446 Patient Has Right to Be Advised of Contact Info for Agencies
    G580 Drugs Treatment Services Administered Only as Ordered by Physician
    G536 A Review of All Current Medications
    G798 Aide Assignment and Duties


    Both monetary and non-monetary sanctions may be given to an agency for condition-level deficiencies, and will definitely be given for immediate jeopardy cases. Non-monetary sanctions can include temporary management and a directed plan of correction and/or education. Monetary sanctions range from $500-$21,000 per day until the deficiencies have been cleared. In addition, there is a suspension of payments for new admissions, which is an immense burden for home health agencies.


    Addressing the Top Most Common Deficiencies

    1. Plan of Care (POC)
      • Ensure all patients have an individualized written POC that addresses the issues identified in the comprehensive assessment.
      • Goals must be specific, objective, measurable, and realistic to the patient’s diagnoses, symptoms, and condition.
      • Ensure all orders for all disciplines include the amount, frequency, and duration of the service provided; all therapy orders include the specific procedures and modalities to be provided; and wound care orders are specific.
      • Ascertain that all medications, treatments, and services are administered as ordered.
        Ensure that the physician is informed of all missed visits to determine if the POC needs to be altered.
    2. Promptly alert relevant physician of changes (G590)
      • Ensure that all clinicians document communication to the patient, the representative, if any, and the caregiver.
      • All physicians issuing orders for the POC must be notified of any changes that may indicate that outcomes are not being achieved or suggest a need to alter the POC, including discharge planning.
      • Notify physicians early and frequently of anything outside of parameters, negative changes, or ineffective medications and therapies.
    3. Services are coordinated to meet patient needs (G608)
      • Integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, and the coordination of care provided by all disciplines.
      • Establish case management models in which the team communicates regularly and documents everything.
      • A user-friendly group location should be set up in the electronic medical record so team members can report to each other on an ongoing basis. Each person caring for a patient should read the report prior to making a visit.


    Continued Survey Readiness

    Agencies must be in continued survey readiness to avoid being cited for condition-level deficiencies or immediate jeopardy. Performing mock surveys, reinforcing home supervisory visits, and performing regular audits through a comprehensive quality program should address inconsistencies in your documentation and help you stay compliant.

    On the other hand, another proactive approach is improving your clinicians’ knowledge and skills through ongoing education. After all, maintaining quality and accuracy in patient assessments translated into the EMR documentation is a better practice than being able to catch errors and deficiencies; as they say, prevention is better than cure. However, while educating clinicians is an effective measure, it is also not an easy task as it requires time, effort, and resources. This is precisely why your quality program should be designed to support re-education of clinicians, with the goal of improving their patient care and documentation skills organically in the long run.

    Moreover, encourage involvement of all staff and contractors in all quality initiatives. For instance, your QA provider should utilize tools for reporting and feedback mechanisms. This includes monitoring clinician progress, capturing weak areas in the documentation, and reporting actionable insights so you would know how to address certain challenges and keep your entire documentation survey-ready.