Free Home Health Agency Licensure Survey Entrance Conference Guide-F-62653 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62653 (Rev. 04/09)

STATE OF WISCONSIN

HOME HEALTH AGENCY LICENSURE SURVEY ENTRANCE CONFERENCE GUIDE (OPTIONAL)
Name ­ Agency Name ­ Administrator Name ­ Substitute Administrator Name ­ Surveyor(s) Name ­ Supervisor Name ­ Clinical Director Survey Start Date License Number

Reference the home health licensure survey guide and the informal dispute resolution procedure.
Standard Survey. DHS 133.06(3)(a-b) DHS 133.06(4)(a)(c-g) DHS 133.06(5) DHS 133.07(1-4) DHS 133.08(1-3) DHS 133.09 DHS 133.10 DHS 133.11 DHS 133.12 DHS 133.14 DHS 133.15 DHS 133.16 DHS 133.17(1-3) DHS 133.18(1-2) DHS 133.20(1-4) DHS 133.21(1)(5)(6) Orientation / Training / Evaluation Health / Personnel Files Infection Control Evaluation Patients' Rights / Complaints Acceptance and Discharge of Patients (all areas including service agreements) Services Provided Referrals Coordination with Other Providers Skilled Nursing Services (all areas) Therapy Services (if provided) Medical Social Services (if provided) Home Health Aide Services Supervisory Visits Plan of Care Medical Records (content and form)

Partial Extended Survey. In addition to above, surveyor will be reviewing specific areas of concern, e.g., physical therapy. Extended Survey. All DHS 133 Wisconsin Administrative Codes reviewed for compliance. Current Weeks = Patient Census. Include all payor sources and PCWs. Exclude only homemakers and companions. Include patients who have home visits scheduled during the week of the survey. Home Visit Sample. (less than 50 = 3) (51 ­ 99 = 4) (100 or more = 5 / An additional selection of records will be reviewed by the surveyor.) Discharge Records. List of clients discharged (including disposition) during past 30-60 days. Personnel. List all personnel involved in patient services. Include discipline and date of hire. Forms / License. 1. Agency license to be observed by surveyor. 2. Written version of patients' rights, advance directives, and service agreement. 3. Copy of annual report and governing body minutes.

Provide surveyor with a copy of the current plan of care for each record reviewed. For each scheduled home visit, provide a current medication list, therapy care plan (initial evaluation if applicable), and home health aide instruction sheet, if applicable.
Home Visit Date Time Date Time Date Time Date Time Date Time Patient / Diagnosis RN PT OT ST AIDE MSW PCW