Unhappy with your survey results? Try an appeal
Unhappy with your survey results? Try an appeal
Indiana agency turns Type 1 into commendation
Most home care agencies receive a "recommendation for improvement" when they go through a survey by the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL.
And most quality managers will work hard to improve the area that received the Type 1 recommendation, which means the surveyor found a problem in one of about 50 performance areas, including treatment planning, leadership, and infection control.
But in some cases, there’s another option to having that red mark removed, and the process for challenging it is a lot simpler than you might think.
One Indiana agency asked the Joint Commission to reverse two Type I recommendations, sending in supporting documentation, and its challenge succeeded. It was even granted accreditation with commendation.
"When the letter came, I was thrilled and gathered all the staff together to read the letter aloud, and there was quite a bit of whooping and cheering," says Julie Bowers, RN, BSN, MSA, executive director of Kosciusko Community Home Care & Hospice in Warsaw, IN. The freestanding agency serves several counties in north-central Indiana.
Fewer than 3% of home care agencies successfully have a Type I recommendation removed, says Gail Weinberger, director of policy and administration for the Joint Commission.
"They have one opportunity to change it, and they would have to make a very strong case why their initial request was not handled appropriately," she adds.
The Joint Commission calls challenges to Type I changes a "revision request," not an appeal. Appeals occur when organizations challenge a decision to place them in preliminary nonaccreditation, Weinberger says.
Agencies have 30 days to challenge
The process for challenging a Type I recommendation works like this: Within 30 days of receiving an official survey report, an organization must send the Joint Commission a letter with supporting materials as to why the Type I recommendation isn’t appropriate. The organization also files a formal revision request form. (See sample revision request form, p. 65.)
After receiving the information, the Joint Commission will contact the surveyor and have the surveyor also review the supporting material. The Joint Commission will not accept any information that was not written or available at the time the survey was taken. So, if the agency or the agency’s state made a change after the survey date, that change cannot be considered when the Joint Commission reviews the challenge, Weinberger explains.
If Joint Commission officials find that the agency is correct and the Type I recommendation was not appropriate, then they’ll revise the survey report, update the Joint Commission Web site listing for the agency’s accreditation status, and send the agency an award letter. If they decide the original Type I recommendation should stand, then they’ll notify the agency that the survey report won’t be changed.
In Kosciusko Community Home Care & Hospice’s case, the challenge worked, and other agencies can do the same. Bowers explains how the agency succeeded:
1. Understand exactly what the Type I is for.
The agency was surveyed in August 1998, and the surveyor wrote a Type I recommendation regarding infection control for the agency’s home health division and an identical Type I recommendation for the agency’s hospice division.
The Type I recommendation, an IC.2, read as follows: "In 3 of 14 visits, it was noted that the prevention of infection was lacking; that is, physical therapist did not have any protective equipment with him, such as a mouth shield, gloves, or any way to clean up spills. In another visit, the nurse did not transport the blood sample to the lab in a hard container, nor did she separate clean from dirty in her car. A physical therapist assistance [sic] did not have any way of cleaning equipment between patients, specifically a folding cane. A nurse used alcohol last when cleaning a port instead of using betadine last as is the recommendation."
Bowers immediately saw that all of these examples pertained only to the home care division and that the surveyor had not witnessed any infection control problems among hospice nurses. Further, while hospice nurses sometimes would fill in for home care staff, the home care nurses never filled in for the hospice staff.
2. Address most important issue first.
Bowers says she felt fairly certain that the agency could at least have the Type I recommendation removed from hospice division, so she tackled that problem first by writing the Joint Commission’s Report Receiving Center a one-page letter explaining why the hospice division shouldn’t be penalized for errors found in the home care division.
The letter stated in part: "Unfortunately, I was not given any forewarning that a recommendation would appear within the Hospice program related to noncompliance with the infection control standard (IC.2) until the written computer report was generated on Aug. 11, 1998. The surveyor stated duplication of the Type I standard in the Hospice program was a function of the computer tabulations, and she could not alter the report. Upon verbal review of the preliminary report, we proceeded to the closing session. On Aug. 12, 1998, I telephoned the Joint Commission on Accreditation of Healthcare [organizations’] office in Chicago and spoke with a representative from the Home Health office whom advised that I file a revision request upon receipt of the Official Accreditation Decision Report."
The letter continued, "None of the visit observations related to this infection control standard occurred during any of the Hospice patient visits. While Hospice nurses cross over into the Home Health to fill case loads during period of low Hospice volume, none of the Home Health nurses cross over into the Hospice program for direct patient care. Therefore, I further request that the revised supplement recommendation for infection control only be assigned to the area of Home Health, leaving Hospice free of any deficiency related to Surveillance, Prevention, and Control of Infection."
3. Answer each recommendation point by point.
Bowers broke the Type I recommendation into four points and she answered each with documentation.
• First, the surveyor had written that the physical therapist didn’t have protective equipment with him. Bowers explained that the physical therapist didn’t have the equipment on him, but he had it in his car. "What happened was the surveyor asked him what he would do in the event a person would have a spill, and he said he’d go out to his car and get his mouthshield or protective equipment," she says.
The agency’s policy does not require physical therapists to keep their protective equipment on their person, and the visit the surveyor witnessed was not an instance where it was needed.
• The second point was about how a nurse transported a blood sample. The nurse had a hard container, but instead of putting the blood sample in that she kept it in a soft-sided container that she kept close to an icepack because it was a 100-plus degree August day, Bowers says.
The surveyor’s other criticism was that the nurse did not separate the clean from dirty items in her car. Bowers points out that the nurse drove a four-wheel drive Blazer that has deeper wells behind its seats. The nurse placed the clean materials in one well and the dirty materials in the other well. So while those materials weren’t separated by the back of a seat, they were separated enough that the dirty and clean would never come into contact with each other.
• The third point was that the physical therapist assistant didn’t have any way of cleaning equipment between patients. This criticism resulted from the assistant’s verbal response to the surveyor’s question and not something the surveyor observed, Bowers says.
The surveyor asked the assistant how she would clean a folding cane. The assistant answered that she would take it back to the therapy office to clean it.
• The last criticism was that a nurse used alcohol when cleaning a port instead of using betadine last.
The agency’s recommendations, along with new nursing literature, only recommend that a nurse cleanse skin with an approved antimicrobial solution. But it doesn’t have to be betadine, Bowers says.
4. Support your challenge with documentation.
For each point, Bowers included some documentation. For what the surveyor observed the therapists doing, she included some edited statements from other staff members who had accompanied staff members during the surveyor’s visit.
"I called staff members involved with the visits and had them document their visit experience," Bowers says. "They wrote what the surveyor said and what they said, and I had the supervisor present with survey visits also document observations."
Then Bowers typed up what they said and she edited out the comments that assigned blame or were emotional.
"My objective was to give an objective critique of the process and to help whoever doing the appeal have a picture of what happened," she explains. "I wrote it more from a logical, if-you-had-to-testify-in-court type of document."
For example, in the case of the physical therapy assistant, a staff nurse wrote, in part, "When the surveyor saw that, she asked [PT assistant] how she would clean that particular piece of equipment. [PT assistant] replied that she would take it back to the therapy office and wipe it off. I did not observe any inappropriate behavior or line of questioning."
To support the nurse’s use of alcohol to clean a port, Bowers sent the Joint Commission a copy of the agency’s policy for dressing change on a subclavian line. The policy says a nurse first should clean the skin using three alcohol swabs, then repeat the cleaning using betadine swabs. But nurses may interchange the order or skip using betadine swabs if the patient is allergic to betadine.
Bowers also sent a copy of a page in the 1998 edition of the Intravenous Nursing Standards of Practice, developed by the Intravenous Nurses Society of Cambridge, MA.
The page includes an interpretation that reads in part, "Intravascular cannula site care should be established in organizational policy and procedure. Site care is defined as aseptically cleansing the skin-cannula junction with an approved antimicrobial solution and application of a sterile dressing."
Once the agency submitted its revision request and supporting material, Bowers waited about two months before she called to check its status. She was told it was still in the audit review committee. A couple of months later, she received the letter announcing that their accreditation status had been changed to that of accredited with commendation.
Ironically, Bowers and Kosciusko home care staff’s celebration was short lived, and the agency will have to undergo an entirely new Joint Commission survey. This is because the agency recently broke off from its affiliation with a local hospital that also was Joint Commission accredited, and the hospital was sold.
As part of the sale agreement, the hospital will get to keep the Joint Commission accreditation and the home care agency will have to start all over.
"I had to sign over the Joint Commission status, and now we have to go through the survey again," Bowers says.
Sources
• Julie Bowers, RN, BSN, MSA, Executive Director, Kosciusko Community Home Care & Hospice, 902 Provident Drive, P.O. Box 1196, Warsaw, IN 46581-1196. Telephone: (219) 372-3401. Fax: (219) 372-3414.
• Gail Weinberger, Director of Policy and Administration, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5766.
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