Free Home Health Agency Licensure Survey Exit Conference Guide-F-62654 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62654 (Rev. 04/09)

STATE OF WISCONSIN

HOME HEALTH AGENCY LICENSURE SURVEY EXIT CONFERENCE GUIDE
(OPTIONAL)
Name ­ Agency Name ­ Surveyor (s) License Number Survey Exit Date

Introduction Sign attendance sheet. Express appreciation. Explain purpose of survey, i.e., initial, standard, complaint, vv. Review the components of the standard survey.
DHS 133.06(3)(a)(b) ................. Orientation / Training / Evaluation DHS 133.06(4)(a)(c)(d)(e)(g) ...... Health / Personnel Files DHS 133.06(5) ........................ Infection Control DHS 133.07(1)(2)(3)(4) ............. Evaluation DHS 133.08(1)(2)(3) ................. Patients Rights / Complaints DHS 133.09 ............................ Acceptance and Discharge of Patients (all areas including service agreements) DHS 133.10 ............................ Services Provided DHS 133.11 ............................ Referrals DHS 133.12 ............................ Coordination with Other Providers DHS 133.14 ............................ Skilled Nursing Services (all areas) DHS 133.15 ............................ Therapy Services (if provided) DHS 133.16 ............................ Medical Social Services (if provided) DHS 133.17(1)(2)(3) ................. Home Health Aide Services DHS 133.18(1)(2) .....................Supervisory Visits DHS 133.20(1)(2)(3)(4) ............. Plan of Care DHS 133.21(1)(5)(6) ................. Medical Records (content and form)

If Partial Extended Survey, Date Initiated: ___________________ Additional components reviewed. Identify and discuss additional area reviewed. If Extended Survey, Date Initiated: _________________ Review the components of the extended survey.
DHS 133.05 ­ Governance. Governing body/professional advisory committee DHS 133.06 - Administration DHS 133.07 - Evaluation. Total Program Evaluation DHS 133.08 - Patients Rights DHS 133.09 - Acceptance and Discharge of Patients DHS 133.10 - Services Provided DHS 133.11 - Referrals DHS 133.12 - Coordination with Other Providers DHS 133.13 - Emergency Notification DHS 133.14 - Skilled Nursing Services DHS 133.15 - Therapy Services DHS 133.16 - Medical Social Services DHS 133.17 - Home Health Aide Services DHS 133.18 - Supervisory Visits DHS 133.19 - Services Under Contract DHS 133.20 - Plan of Care DHS 133.21 - Medical Records

Total Records Reviewed: _____________________ Total Home Visits Conducted: _______________ Positive Findings (If Applicable) Survey Findings and Observations - Review Statement of Deficiencies. Plan of Correction - Refer to Home Health Agency Survey Licensure Guide. Plan of correction must include who, what, how, when compliance will be met and internal monitoring mechanisms to maintain compliance. Sign and date form F-62567 before returning. Completion Date For Corrections: __________________ or 30/60 days maximum from survey exit date. Form F-62567 with plan of correction must be received in the surveyor's office by 10 working days from date received by mail or on-site. Entertain questions/comments. Give administrator F-62579, Post Survey Questionnaire. Express appreciation. Depart. At completion of Exit Conference, contact support staff to report: License Number, Name of Agency, Start Date, Exit Date.