Skip to content

Tips for Avoiding Common Survey Deficiencies

    Surveys are unannounced yet foreseeable, making it crucial for home health agencies to remain survey-ready. Survey deficiencies can have severe consequences for a home health business, particularly if they pose a risk of causing serious harm to patients.

    The top 10 home health survey deficiencies identified by CHAP in 2022 center on POC compliance, medication management, and infection control. Below are best practices for avoiding deficiencies in these areas:

    The Plan of Care (POC)

    • Prior to sending the POC for the physician’s signature, check that it is complete with all the required information.
    • Review the POC for accuracy and pay special attention to allergies, interventions, medications, emergent care, and risk for hospitalization.
    • Review the medical records for follow-through of physician orders, and acquire new orders as needed to update the POC.
    • Introduce a process to verify if orders were followed during visits. Set up a quality indicator to trigger focused audits for order types that are frequently not followed, such as wound care and missed visits. Then, provide specialized training to clinicians in these specific areas.
    • Review patient records to confirm that any changes in condition were reported to the appropriate physician for potential adjustments to the POC. Utilize hospitalization, incident, and emergency room logs to identify records indicating the patient may have experienced changes in their condition.


    • Conduct regular home supervisory visits to verify that ongoing medication reconciliation is taking place in the home. Create a Personal Improvement Plan (PIP) for better medication management. Provide training to clinicians using scenarios identified during audits.
    • Examine all medications currently used by the patient to spot any possible adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

    Infection Control

    • Determine the agency’s infection rate. Make sure that the infection control program has a process for monitoring infections and promptly notifying physicians of any new infections. The QAPI program should also include tracking, trending, and analyzing infection data.
    • Conduct regular infection control in-service sessions and competence evaluations. Perform home supervisory visits to validate compliance.

    Other tips:

    • Conduct regular clinical record reviews, including timely investigations of emergency department visits, re-hospitalizations, and complaints, while providing staff education as needed.
    • Plan an annual mock survey, including on-site visits and interviews with patients and staff.

    Surveys examine a home health agency’s dedication to upholding excellent patient care. Quality Assurance (QA) is crucial for making sure your clinical records, like OASIS and the Plan of Care, are ready for surveys. Accurate and consistent documentation is vital for demonstrating effective care and regulatory compliance. By maintaining thorough and comprehensive documentation and application to best practices, home health agencies can face surveys with confidence, proving their commitment to patient safety and better outcomes.