Common and Avoidable Survey Issues – Expired documents & missing supervision

Last time, we started our series on some of the common survey deficiencies with a discussion of signatures.  This week, we’ll tackle another popular issue:  the myriad documents in a personnel file.

Bur first, a word about regulators…. They’re so narrow-minded, aren’t they??  Here you are giving superior care to your patients and the documentation in a personnel file of someone’s CPR certification, or car insurance, or nursing license has expired.  This should hardly be a big deal!  Well, it is.  It is your responsibility to make sure the individuals who render care as part of your organization meet regulatory guidelines.  One such standard is the presence of current documents. And verbal assurances from the staff member don’t count.  You need physical evidence, such as the renewed CPR card, new insurance card, etc.

Our blog entitled Tracking the Details provides some suggestions for developing a computerized or manual system to track these items.  Our blog on the QI process reinforces the role of auditing to spot these issues in time to correct them.

It can’t be over-emphasized that your actions require follow-through with regard to expired documents.  If you remind the staff member to produce a current piece of information by a certain date and the item is not received, remove the individual from active status.  This means transfer the patients to another staff member whose personnel file meets all regulatory guidelines.  I can guarantee that if you do this one time, word will spread throughout your organization that this is not an area where you can be flexible.

Supervisory visits are another needless deficiency during a survey.  The easiest way to avoid a problem in this area is to be organized and use technology to do your job.  The schedule for supervisory visits hasn’t changed since the beginning of time, it seems, yet agencies frequently run late in performing them.  Some companies forget them entirely.

Check out our blog entitled Tracking the Details for some tips to avoid this citation.  In a nutshell, success on this rule requires an organized system and holding one person accountable.  This individual must create a calendar and schedule the supervisory visits for every episode of care.  Some agency software programs allow you to do this in the system and generate a report.  Other companies that aren’t as technologically savvy use a calendar program.  Whatever you do, plan out the episode ahead of time and note the dates of the supervisory visits. Then issue a reminder to the clinician and make sure to follow up on the documentation.

Surveys are definitely stressful times, and we all have a tendency to watch the calendar and scramble as our imagined survey date approaches.  The key is obviously to be prepared for survey every single day and to make certain things so habitual that you automatically stay within the rules.  Join us next time as we explore the Plan of Care and some ways to avoid being cited.