Kornetti & Krafft’s approach to licensure survey is simple:
“An ounce of prevention is worth a pound of cure.”
- Ben Franklin
This activity, although frequently treated as a “special event” with attention paid to key elements of clinical care and operations for a concentrated period of time leading up to the actual survey, encompasses behaviors that require attention and execution on a daily basis. Our survey prep program mimics the first level survey an agency engages in for both initial or standard re-licensure.
Prep Mode Clinical Record
Audit On-Site Activities Logs, Files &
Next Steps Summary of Findings Recommendations
I. Clinical Record Audit
Determination of record volume will be tied to the agency’s average daily census (ADC) with input from agency leadership. Record audits will be identified through a review of agency dashboards and reports in conjunction with agency recommendations as desired. The Mock Survey process has the capacity to provide the agency detailed information about the operationalization of key elements related to care coordination and care planning in addition to the identification of risk in existing clinical documentation. This clinical record review can be completed remotely, with log-in credentials to agency electronic medical record (EMR) provided to Kornetti & Krafft or completed as a component of on-site activities.
II. Onsite Activities
Onsite activities will begin with an unscheduled arrival date/time with an assessment of agency personnel response to the surveyor. Review of logs, files and agencies processes provide a trained eye for inspection of operational behaviors. With newly implemented Conditions of Participation (CoPs) detailed review of current Quality Assurance Improvement Process (QAPI) plan, activities and associated reports will be completed in association with QAPI team member discussion and queries as indicated. Coordination and completion of home visits with nursing and therapy, clinicians and home health aid will focus on operationalization of agency processes related to patient-centered care deliver, infection control procedures and care coordination/physician communication strategies. Prior to completion, Kornetti & Krafft will complete a preliminary exit interview in a format consistent with surveyors in the state of agency licensure.
II. Next Steps
Kornetti & Krafft will provide a formal write up of the complete mock survey findings that includes all checklists and audit forms completed. This will
provide the agency with details on areas where additional training, education or review may be warranted prior to entering into their state survey window. Kornetti & Krafft will also include recommendations to address any deficiencies found during this self-assessment process to assist the agency’s
proactive completion of an internally-driven corrective action plan.
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