JCAHO survey can be good primer to clean house
JCAHO survey can be good primer to clean house
Director views survey as a learning experience
Most home care quality managers aren’t very happy if their agency receives any citations after an accreditation survey. It might surprise them, however, to learn that a Columbus, OH, home care director was pleased after her agency’s initial survey, despite receiving a laundry list of citations.
But then most agencies have more than a month of service behind them when they’re first surveyed. Community Home Health Services Inc. had been open for little more than the required 30 days when the agency was visited by a surveyor from the Joint Commission on Accreditation of Healthcare Organizations of Oakbrook Terrace, IL.
"We crammed three to five months worth of education in three weeks to prepare for the survey," says Lisa Munnerlyn, administrator for the agency, which opened in spring 1999.
When the Joint Commission surveyor came back with a lengthy list of problems the agency needed to correct, including one that required a response within 30 days, Munnerlyn wasn’t surprised or distressed. After all, the surveyor was doing the small agency a big favor by helping managers find problems early on. Plus, the agency would have a chance to demonstrate how well it has improved documentation through a follow-up or focus survey in October 1999.
"Initially, the survey was looked at by some of our staff as, Oh gosh, this is terrible. We did these things wrong,’" Munnerlyn recalls. "But to me, it’s a good thing."
The surveyor gave the agency some guidance, and the survey process gave the agency an opportunity to correct mistakes and try again. "I reassured staff that this is a learning process," she adds. "These are minor paperwork issues that clearly could be cleaned up and dealt with in a way that would not cause us to lose accreditation."
Whether a survey is an agency’s first-ever accreditation survey or a triennial survey, quality managers certainly should view it as part of the staff’s learning process, says Donna Larkin, a Joint Commission spokeswoman.
"The surveyors are there to work with an organization to improve the quality of care," Larkin says. "At any survey, the surveyors are asking questions about organizations so they can help the organization meet the quality standards we have for patient care."
A second chance
The Joint Commission decides when it is necessary to conduct a focus survey or when an agency should submit a written progress report. In Community Home Health Services’ case, the surveyor thought it would be best to conduct a follow-up survey. Munnerlyn says she has welcomed the opportunity to have a second chance at the survey process: "This is what we consider the big survey."
Many of the citations were for documentation omissions or other small errors that were easily corrected, Munnerlyn says. A few have required the agency to create new forms and policies. Either way, she says it’s important for the home care staff to focus on the positive aspects of the survey, such as the fact that a surveyor has helped them zero in on areas they need to improve. And since the agency is so new, they can use this kind of help to improve quality issues before they become firmly entrenched in habit and culture.
"The surveyor was pretty informative in assisting us in what we needed to do and in putting us on the path of righting the wrongs we had out there, and there weren’t many," she adds.
Munnerlyn describes some of the agency’s survey problems and how these were corrected:
1.Organization leadership compliance problems: The standard cited was LD.5: Organization leadership complies with applicable law and regulation. This Type 1 recommendation cited five problems, which the agency needed to correct and document on a progress report within 30 days. These errors and corrective measures were:
• No evidence that employees were offered hepatitis vaccinations within 10 days of employment: Managers were supposed to ask employees to obtain a hepatitis B vaccine within 10 days of being hired. If an employee declined to do so, this should be noted in the files. "But we didn’t have documentation of whether two employees had declined or accepted the vaccination," Munnerlyn says.
First, Munnerlyn called an emergency management meeting with the human resource director and the director of nursing. The three managers decided the simplest solution would be to fire the two employees and rehire them, then offer them the opportunity to be vaccinated for hepatitis B. The employees lost no benefits or seniority by the action, and this brought the agency up to requirements.
Also, managers now have employees sign a hepatitis B vaccine acceptance/declination form that says, in part, "I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself." Then the employee checks the decline or accept box.
• Material safety data sheets identifying substances hazardous to employees were not on file as required by the Occupational Safety and Health Administration (OSHA): Managers filled out material safety data sheets for all office hazardous substances, including copier/fax/printer toner, cleaning solvents, and others. The forms also contain information about possible hazardous substances that home care staff might encounter in client’s homes. These forms are kept in a central location in the office and are accessible to all staff.
• Employee health files were not kept separate from personnel files as required by the American Disabilities Act: Health files now are kept in a locked room of the office with only one key that is held by the administrator, meeting ADA requirements.
• The organization did not verify the licensure of direct and contracted employees: The surveyor found four employment files for which there was no evidence that a written or verbal follow up was conducted on potential employee’s references, job history, educational background, and licenses and certifications. The managers created a job qualification form that the human resource director fills out for each potential employee. The form serves as a screening tool, and is used to document training and other background information. (See hiring requirements form, inserted in this issue.)
• Employees with potential for exposure to hazardous waste were not provided with personal protective equipment, except for gloves: The agency now provides those employees with personal protective equipment, including latex gloves, protective goggles, vinyl aprons, and face masks. A documentation tool has been designed to give evidence that this equipment is available to the nursing and care staff. The tool, "Protective Equipment," reads: "I, [employee’s name], have been orientated on the proper usage of the following protective equipment, and have received the equipment for my personal use whenever necessary during the hours that I am on duty as a home care person for Community Home Health Services Inc. Items given: goggles, apron, gloves (latex), mask."
2.Human resource problems: The surveyor said there was no documentation that the agency had a competency assessment program.
"Since the survey, we have devised a competency test for all field staff," Munnerlyn says.
The agency uses both contract workers and employees; now the written portion of the competency assessment is given when people apply for contract work or a job. This way, it’s already on hand if they are suddenly needed to work during a particularly busy week, she adds.
Also, the competency assessment helps the agency gauge potential workers’ strong and weak points.
The skilled assessment involves hands-on testing with a Hoyer lift and transfers. The hands-on assessments are scheduled once potential workers meet the other criteria.
Then, all who have passed the competency assessment tests are placed in a holding pool of available workers.
Another human resources problem involved job descriptions and qualifications for all staff. The surveyor said they needed to include job qualification guidelines for potential contract workers, as well. They wrote qualification descriptions for therapists, social workers, and nutritionists, even though the agency does not employee those disciplines.
"Now, the people we contract with have to meet our qualifications," Munnerlyn says.
3.Ethical issues in marketing: The agency’s marketing brochure stated that the agency could provide therapy services. The surveyor said that was not accurate because those services could only be provided by firms that contract with the agency. "She said we were misrepresenting our services; so we redesigned our brochure to show what our services are, and deleted mention of physical therapy or occupational therapy," Munnerlyn says.
4. Document patient rights discussions: The surveyor found two active patient medical records that had no documentation that the patient rights were reviewed with the patient and family. The agency’s managers quickly corrected that omission through staff and management education. Now, the director of nursing and any registered nurse who conducts an initial assessment are required to bring a Patient Bill of Rights form to the patient’s home on the first visit.
"The director of nursing reviews that with the client, and then there’s a checkbox to mark to let us know the information has been reviewed," Munnerlyn explains. "The patient signs it, and a copy is put in the case folder."
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