MOCK SURVEY DEFINED
Mock Surveys are a great tool to assist organizations in preparing for an imminent survey. Whether recertification or initial certification survey, a mock survey is recommended to assist in identifying any gaps in compliance and in developing a corrective action plan to correct any issues prior to the actual survey. This can help to ensure that there is a smooth survey with everything required in place and limited to no deficiencies cited.
BENEFITS OF A MOCK SURVEY
Having another set of objective eyes on your day-to-day processes, policies and care of patients will provide feedback on what your agency staff is doing well and what needs correction and/or improvement. The ultimate accomplishment is improved patient care while minimizing the risk of survey citations. The mock survey process resembles the Medicare Survey Process and assists in identifying survey risk areas, allowing you to begin work on correcting potential deficiencies. This self-identification of high-risk and/or problem-prone areas can lead to incorporating these areas into your QAPI program which will show that you have been proactive and have corrected the deficiency to demonstrate compliance. This is a process HPS has utilized and successfully saved agencies from survey deficiencies.
Clinical Consulting Services
- HPS offers several clinical and operations consulting services that will minimize risk, maximize productivity, and optimize your agency’s revenue cycle and overall operations. Click here to learn more about Clinical Consulting services.
- HPS has a team of experienced reviewers that have led agencies across the country through numerous levels of review. Click here to learn more about Medical Review Consulting services.
- HPS offers several clinical and operations consulting services that will maximize productivity, and optimize your agency’s overall operations. Click here to learn more about Operations Process Consulting.
WHAT YOUR STAFF WILL LEARN
Policies and Procedures, in most agencies, are to the letter of the law and meet every requirement of the Conditions of Participation (CoPs). However, having them perfectly documented in a manual does not make your organization compliant. Regardless of ongoing training, there are times when your staff have veered from the correct course, and no one stops them. This detour then turns into the path that everyone accepts as being correct and the downhill slide toward noncompliance gets steeper and steeper.
Mock Surveys assist in identifying all the side streets your staff have decided to take and helps to get them back on the right course before the actual survey happens. Due to numerous updates to the Conditions of Participation and the focus that surveyors have been instructed to take, keeping up with every twist and turn can be overwhelming and even the best of leadership teams can veer off course. Allowing a team of dedicated, compliance driven mock surveyors to perform a mock survey will help identify any areas of concern that your policies define as compliant, but your documentation and daily practices do not reflect that compliance.
ITEMS THAT WILL BE REVIEWED
The Mock Survey conducted by HPS CHAP Certified Consultants includes, but is not limited to a review of the following:
- Home Care or Hospice Organizational Structure
- Service/Business License & CLIA certificate (if applicable)
- Agency Policies & Procedures
- Agency Contracts
- Minutes of Governing Body
- Operating Budget
- Continuing Education Program
- Infection Control Program
- Quality Assessment & Performance Improvement (QAPI) Program
- Emergency Preparedness Program
- Patient Records/Documentation, including OASIS transmission (HHA)
- Patient Admission Packet including Marketing Material
- Home observation patient visits with agency staff
- Sample of Personnel Records
- Home Health Aide Training and/or Competency Program
- Case Conferences, if applicable
- Bereavement Program (Hospice)
- Volunteer Program (Hospice)
Learn More About CHAP Certified Consultants at HPS
HPS CHAP Certified Consultants will be available to not only conduct the mock survey but to assist in any way needed to fully implement any corrective actions resulting from these findings. Consultants will also be available to assist you with any aspects of the actual survey. Click here to learn more about our CHAP Certified Consultants.
SIGNIFICANT PROGRAMS RELATIVELY NEW
It might depend on your personal definition of “relatively new”, but the 2016 & 2018 regulations and required compliance for Emergency Preparedness (EP) and Quality Assessment & Performance Improve (QAPI) Programs are both hard core requirements of the CoPs and a focus of surveyors. While the effective dates have given us some time to better comprehend what they require, these requirements have continued to evolve since their effective dates. EP and Infection Prevention & Control have come to the forefront, more than ever, during the world-wide pandemic and the still active United States Public Health Emergency. In addition, EP has heavily impacted the states that have endured significant natural disaster activity since the implementation of the regulation.
QAPI programs have also continued to be massaged and stretched into not only being what they need to be to pass survey, but to be a very integral part of agencies monitoring outcomes for improvement and corrective actions for deficiencies found. QAPI has also been promoted as one of the programs to assist home health agencies in monitoring outcomes that will impact how the agency fares in the new Home Health Value-Based Purchasing Expansion Model.
Mock Surveys are key in assisting agencies with the review of these imperative programs to identify any weaknesses that the home health or hospice can strengthen prior to the actual survey.
FEEDBACK PROVIDED DURING A MOCK SURVEY
HPS CHAP Certified Consultants will meet with your team at the end of each day during a mock survey to share their findings and allow for any evidence to be presented and discussed that would help to eliminate any deficiencies. The consultants will provide education throughout the process and during the exit meeting on the final day, there will be an additional review of all findings and the specific tags that would present risk for deficiencies to be cited during an actual survey. The mock surveyors will discuss the top risks identified and provide feedback on where the agency needs to focus problem solving efforts regarding the findings. A detailed report that includes findings from the mock survey and recommendations for correction of any deficiency risks will be provided shortly after the mock survey is complete. HPS will provide the opportunity to review the final report and agency next steps during a conference call.
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