June 21, 2005

Provider Letter Update: HCS Survey by DADS

A recent provider letter outlined what Home and Community Support Services Agencies (HCSSA) can expect during a DADS survey.

Entrance Conference
The survey will begin with an entrance conference with the survey administrator, the supervising nurse and an authorized agency representative. At this time the survey process will be fully explained. During the course of the survey a minimum of 11 clinical records will be reviewed, and at least 3 home visits conducted. Also, the surveyor will examine the following systems:
- administrative records;
- complaint tracking system;
- quality assurance plan;
- policies and procedures; and
- employee records and qualifications.

During the survey the surveyor will require copies of all documents reviewed to assist in determining any findings.

Exit Conference
After the conclusion of the survey, an exit conference will be conducted on site with agency representatives. At this point, any preliminary findings will be explained and all in attendance will be required to sign an attendance sheet.

Statement of Deficiencies
A statement of deficiencies will be mailed to your agency following the exit interview. Licenced agencies will receive a statement within 10 business days, Medicare-certified facilities within 10 calendar days.

Plan for Corrections
If deficiencies are cited, your agency will have 10 calendar days to return a Plan of Correction (PoC) to the DADS Regional HCSSA manager addressing the deficiencies and estimated correction dates.

Informal Review of Deficiencies Process (IRoD)
If you disagree with any cited deficiencies, you may submit an IRoD form. This must be submitted on agency letterhead, and a PoC must still be submitted for each deficiency, regardless of whether you file an IRoD. You also have 10 calendar days from the receipt of the statement of deficiencies to submit this form.