The Benefit of Connecting with a Hospice Consultant for a Mock Survey

Surveys are a fact of life. For Hospice services, in order to participate in Medicare, the hospice must be certified as meeting certain Federal requirements or Conditions of Participation (CoPs), and standards for health and safety. Hospices are surveyed at least once every 3 years to verify their compliance with Federal requirements, either by State agencies or by a CMS-approved accrediting organization.

The primary goal of any survey is to assure that the patient’s rights are being met and that quality-of-care concerns are identified. According to April McLain, MBA, RN, HACP, Hospice Consultant, “Two reports published in 2019 by the OIG, “Hospice Deficiencies Pose Risks to Medicare Beneficiaries,” and “Safeguards Must Be Strengthened to Protect Medicare Hospice Beneficiaries from Harm,” places further focus on the frequency of deficiencies and oversight and enforcement.”

Survey challenges facing Hospice Organizations include:

• Staying current with regulatory requirements
• Maintaining policies and procedures to meet the requirements of the CoPs
• Assuring documentation fully captures the care planning processes and care provided
• Maintaining staff education and training
• Reporting quality issues
• Assuring patient rights are being met

How does the Consultant team assist with these challenges?

With the vast number of regulations, having a Mock Survey to identify the primary areas of deficiencies, allows the organization to focus their survey preparedness efforts on those issues that are most problematic and may lead to cited deficiencies during the survey.

“Conducting a Mock Survey allows the hospice organization the opportunity to safely ask questions and seek clarification of standards which is not generally possible during survey,” states McLain. “Staff participation during the mock survey process will help the staff feel more comfortable interacting with surveyors during the real survey.”

By conducting a Mock Survey, our Consultants work with an organization’s leadership, clinical and support staff to uncover deficiencies and ensure regulatory compliance. The Consulting team works with each organization and the mock survey is tailored to meet the needs of the organization with a comprehensive assessment for regulatory compliance. A focused review of specific regulatory challenges is based on the organization’s needs.

The Mock Survey will include:

• Systematic assessment of the organization’s compliance to the Medicare Conditions of Participation as well as standards of applicable accrediting body
• Review of organizational policy and procedures for compliance
• Review of medical record documentation care planning process
• Review of assessment processes by all disciplines
• Assessment of staff training
• Observation of direct patient care
• Review of documents, policy, and procedures
• Review of the medication management processes
• Review of patient rights

The final report will include details of issues identified during the mock survey and recommendations for compliance. The report can be used by the organization to prioritize its survey preparation efforts and focus on the most problematic areas identified.

Organizations that have undergone a survey and are faced with writing a corrective action plan can benefit from the expertise of the Consultant team who can assist the organization formulate and monitor the plan. This assistance can include:

• Reviewing the corrective action plan for completeness
• Assisting with the development of monitoring strategies
• Providing staff education and training

With experienced healthcare organization surveyors with extensive knowledgeable of current regulatory standards, the Consultant team partners with your organization to provide insight into the survey process and help the organization identify and correct potential deficiencies.