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Home Health Agency (HHA) Survey Protocol released

The new Conditions of Participation (CoPs) for Home Health Agencies (HHAs) became effective on January 13, 2018. On the heels of that, the Centers for Medicare & Medicaid Services (CMS) Quality, Safety & Oversight Group (f.k.a. “Survey & Certification Group) released the revised HHA survey protocol which is State Operations Manual (SOM) Appendix B. Information in the QSO memo includes:

  • The new ASPEN tags for each of the new CoPs and standards will be available in the ASPEN system for surveyors to use starting January 22, 2018.
  • Level 1 and Level 2 standards, which are used for standard and partially-extended surveys, have been updated based on the new CoPs. A table of these standards is included in the memo.
  • The HHA survey process has also been revised, specifically with changes to Task 1, Pre-Survey (Offsite) Preparation and Task 3, Information Gathering.

Changes to Task 1 – Pre-Survey (Offsite) Preparation

To optimize the amount of time a surveyor spends planning for a HHA survey and to start to better utilize the offsite prep time reviewing potentially avoidable events, surveyors will now review 3 CASPER reports instead of 6. These CASPER reports include:

  • Risk Adjusted Potentially Avoidable Event Report (12 Months)
  • Potentially Avoidable Event Report: Patient Listing (12 Months) – this report provides the names of the patients who experienced the events in the prior report, Risk Adjusted Potentially Avoidable Event Report. Surveyors are instructed to prioritize patients who are listed under multiple areas of this report for review.
  • Agency Patient-Related Characteristics Report – this report looks at several OASIS data elements including:
    • HHA patient diagnostics
    • Home care diagnoses
    • Agency statistics

Surveyors are expected to identify potential areas of concern when the agency’s indicators exceed national reference points in these areas:

  • Acute Conditions
  • Patient Diagnostic Information
  • Home Care Diagnoses

Task 3 – Information Gathering

The other HHA survey task that has changes is Task 3, Information Gathering. The minimum sample size/number of clinical records to be reviewed on HHA surveys has been updated. If surveyors identify deficient practices, they may review more records or conduct more home visits to assess compliance.

Per CMS, the updated HHA Survey Sample Size is as follows:

# of unduplicated skilled care admissions for 12 months prior to survey Active Patient Sample – Record Review Only Active Patient Sample – Record Review + Home Visit Discharged Patients – Closed Record Review Total Survey Sample
< 300 2 3 2 7
301-500 3 4 3 10
501-700 4 5 4 13
701+ 5 7 5 17

Read the January 12, 2018 QSO memo, “Home Health Agency (HHA) Survey Protocol – State Operations Manual (SOM) Appendix B Revised” (Ref: QSO-13-13-HHA rev. 1.16.18).

Is your HHA preparing for an upcoming survey? Contact CMS Compliance Group today to learn about our compliance and quality improvement services for Home Health providers

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