CHAP - Impact of Changes to the CMS Survey Guidelines on the CHAP Accreditation Process
Oct 11, 2011
CHAP has been an approved “deeming authority” by the Centers for Medicare and Medicaid Services (CMS) for home health since 1992. The initial approval and subsequent renewals of the CHAP deeming authority, most recently in 2008, resulted in the approval of CHAP accreditation processes and related policies and procedures.
CHAP, as part of our deeming authority granted by CMS, is required to offer a program that at least meets federal requirements; however, is not required to follow the specific survey protocols. The CHAP accreditation process is a comprehensive onsite review of all CHAP Standards for CORE and Home Health. During the course of a CHAP Site Visit for Initial or Renewal of Accreditation, all Conditions of Participation (CoPs) are assessed for compliance.
When there are changes to the CMS processes described in Appendix B of the State Operations Manual, CHAP takes the opportunity to review those changes against our own processes. Earlier this year, CMS announced changes to the home health survey process. In the updated Appendix B of the State Operations Manual (https://cms.gov/manuals/Downloads/som107ap_b_hha.pdf,) CMS published the new survey guidelines which they believe “strengthen the survey process while making it more effective and efficient to assess, monitor, and evaluate the quality of care delivered by an HHA”.
The intent of the change was to ensure more focus on actual patient care delivery and support consistency in citations from state survey agencies, especially in regards to citation of condition level deficiencies. CHAP examined all of the changes and made some adaptations in the process we implement to accredit home health organizations who seek deemed status, specifically, in the area of home visits and record reviews.
Based on the number of unduplicated admissions in the most recent 12 month period prior to an onsite visit, CHAP has always applied a standardized methodology to determine the number of home visits to observe, and the total number of clinical records to review. While the record review sample by CHAP Site Visitors has always been slightly larger than that selected by State Agency surveyors, CHAP has increased the number of observed home visits required to match CMS.
CMS |
Unduplicated Skilled Admissions in Recent 12 months. |
Min # Of Record Reviews Without Home Visit |
Min # Of Record Reviews With Home Visit |
Total Record Reviews |
< 150 |
5 |
5 |
10 |
150-750 |
6 |
6 |
12 |
751-1250 |
8 |
8 |
16 |
1251 or more |
10 |
10 |
20 |
CHAP |
Unduplicated skilled admits recent 12 month period |
Minimum # of RR without home visit |
Minimum # of RR with home visit |
Total record reviews |
Less than 150 |
5-6 |
5 |
10-11 |
150-750 |
8-10 |
6 |
14-16 |
751-1,250 |
10-12 |
8 |
18-20 |
1,251 or more |
12-14 |
10 |
22-24 |
The new survey protocols were effective May 1, 2011 and CHAP, at that time, implemented those changes for any Site Visits conducted as of May 1, 2011.
Beyond this important change, we have determined, after review, the CMS changes essentially reflect activities already in place under a CHAP home health accreditation with deemed status site visit. Consumer records selected for home visits or record review follow a stratified case mix type selection.
As stated above, CHAP initial and renewal site visits are comprehensive and the Site Visit examines all of the CORE and Home Health Standards of Excellence around structure and function, quality of care and services, management of resources and long term viability. The CHAP Standards of Excellence are cross-walked with the CMS standards and conditions, therefore all CMS Level 1 and Level 2 standards and Conditions of Participation are evaluated.
Interviews of staff and management have always played an important role in information gathering as part of the CHAP Site Visit, and Site Visitors, through the pre-site visit review of the Self Study, can access similar information for probes and analysis augmented by review of the last site visit and any Plans of Correction. Readiness for the CHAP site visit also already reflects the same requirements as CMS. CHAP performs renewal of accreditation site visits at least every 36 months. CHAP has long used a similarly structured process guide for the site visit itself, beginning and ending with Entrance and Exit Conferences.
We will continue to assess the CMS changes as we continue to monitor changes in federal and state regulations, and in our industry, to ensure that the CHAP accreditation process continues to reflect best practices and emerging regulations. CHAP accredited home health organizations who select deemed status can rest assured that their Site Visit experience will continue to be robust and interactive, as always, and that our efforts are constantly directed at making accreditation a valuable experience. To this end, we are releasing 2012 standards for public comments in October 2011, and plan a launch of our upgraded CARES (Computer-Assisted Accreditation Review and Evaluation System) for early 2012.
Please see related articles in this and future newsletters as well as frequent updates on our web site at www.chapinc.org. Questions or inquiries are welcome at education@chapinc.org.