Over the last few years, I have had a recurring conversation with a number of my clients. Generally, this conversation occurs during or immediately after a survey. Most providers dread surveys. In most cases, this is a result of previous survey experiences. There is nothing like having the state agency come into your offices, review your files, accuse you of not doing something the way you are supposed to be, demanding you fix it and giving you little or no recourse to challenge the findings.
There is one particular facet of the survey process that many providers find more irritating being cited for doing something a surveyor told them to do in the past. Let me explain. During a survey, the surveyor will point out an area in which she feels the provider is deficient. Occasionally, the surveyor will then offer her “advice” (by advice I mean that the surveyor will tell the agency “this is how you ought to do it”) on what the agency should do to correct this problem. The agency, in turn, makes the changes as recommended by the surveyor. Having done what the surveyor told them to do, the agency is quite surprised when, during the next survey, they are cited for doing what the surveyor told them to do in the first place.
This is not as uncommon as you might think and illustrates a few key points. First, the survey process is rather subjective. The same agency can be surveyed by two different surveyors and obtain wildly varying results. This can be the result of a number of things. The surveyors may have focused on different areas; the surveyors may have different understandings of the rules; or the surveyors may simply have different understandings of the what they are looking at when they review the agency’s files.
More importantly, you cannot rely on the advice of surveyors. Yes, the surveyor should have a solid understanding of the regulatory requirements, but they do not have any authority to speak on behalf of the state agency or CMS. A surveyor may be offering you advice based upon what she has done when working in home care or hospice, she may be offering you advice based upon what she has seen in previous surveys, or she may simply be offering you her opinion on how this particular area ought to be handled. Regardless, if the surveyor is wrong, you cannot later say, well the surveyor told us to do it this way.
I have seen clients change a form or procedure to please a surveyor only to cited for the same issue during the next survey. I have also had clients cited by a surveyor for doing something the surveyor told them to do. Neither the state agency nor CMS cared that a surveyor had told them to do what they were cited for doing. In fact, the usually response is that surveyors are not supposed to be giving advice.
Another issue is communication. You may think you understand what the surveyor wants you to do, but either you or the surveyor may be misunderstanding each other. This can lead you to implement a process that was not actually what the surveyor recommended. (That is why CMS and states with licensure publish regulations and policy documents.)
Finally, you may implement exactly what the surveyor wanted, but your next surveyor may feel there is a more appropriate way to implement the standard. In other words, the next surveyor may have different preferences.
I always tell clients to take what the surveyor says with a grain of salt. Wait until you receive the survey report and then decide what action needs to be taken, without relying upon what the surveyor said during the survey. (This is also good advice, because what they surveyor mentions during the survey and what you are actually cited for are not always the same.)
Ah, the survey process. Lots of subjectivity, no right to appeal. But I am not even going to start talking about that today.
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An issue that has come up repeatedly in the last few months is when does medication assistance become medication administration. This question is important to home care providers, because administering medication is not something a personal care attendant or a home health aide should be doing. Many a home care agency has strayed into home health, by having a nurse set up a medication planner for a patient. The agency in this case assumes that filling the medication planner is just another form of assistance.
In fact, filling the medication planner, while not administering the medication in the sense of placing the pills in the patients mouth or injecting the patient with a syringe, often falls outside of the scope of medication assistance. Most jurisdictions, especially those that offer a personal care agency or home care (non-skilled) agency license, define the term medication assistance.
Each state provides a slightly different definition. For example, in Utah, a CNA can actually check the dosage the patient is about to self-administer against the medication label. In Indiana, home health aides and attendants are allowed to remind a patient that it is time to take their medications, open the preset medication container for the patient, and assisting the patient with handling or ingesting non-controlled substance medications. The state of Washington allows attendants and aides to provide a level of assistance similar to that of Aides in Indiana.
They important thing to know is what your state defines as medication assistance. Your aides should be made aware of the specific parameters of medication assistance. Most home health agencies include this as part of their annual home health aide training. For home care agencies, it is every bit as important that you attendants/companions/personal care aides are always aware that it is not appropriate to administer medication to a patient. They might not see how placing the pills in the patients mouth is different from administering medication to their own children or even different from handing the pills to the patient, but it is and the consequences of administering medications can be rather severe for the caregiver and the agency.
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