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State Survey Readiness Tips

What to do when a Regulatory Agency (Surveyor) arrives at our facility or branch site:

o Accept / request the visitor’s business card
o Inform them you will contact administration
o Offer them a seat.
o Call Shannon Johnson or Rachel Denholm, Managers Clinical Compliance

If they are not immediately available, call;
o Amy Lowe, Director of Clinical Services
o Stephanie Cain, President
o You must reach someone in person. Do NOT leave messages. Do not use Qliq.

• Who is Hospice’s Administrator?- Steph Cain (Back up Amy Lowe)
• Who is Hospice’s Patient and Family Care Coordinator? Amy Lowe (Back up Dawn Curry)

• Wear your name badge at all times on your top
• Tidy up your work space and cover all patient information (HIPAA)
• Keep idle chit chat to a minimum
• Professional behavior at all times
• Do not offer surveyors food or drink
• Answer only questions that are asked; don’t offer additional information or conversation
• NEVER say “I don’t know”. Instead say “Let me check with (whomever you think will have the answer…”my manager”, “my director”…) and I will get back to you.”

• How Many Medical Directors does Our Hospice have? 1
• Who is Hospice’s Medical Director? Dr. Anderson

• Physician
• Nursing
• Medical Social Worker
• Home Health Aide
• Counseling (Bereavement, Dietary, Spiritual)
• Volunteer
• Therapy – (Occupational, Physical, Speech)

• Hospice physician and Attending physician (if appl) certifies patient as terminally ill, with a medical prognosis of 6 months or less to live if the illness runs its normal course.
• The patient (or representative) is ready to change from aggressive treatment to cure to now focus on palliative (comfort) care to address symptom management to improve quality of life

• Routine Home Care
• Respite Care- short term care (5 days) to provide the caregiver a break
• General Inpatient Care (GIP)- short term care in the Inpatient facility for acute symptom management
• Continuous Home Care- short term care for acute symptom management in the home

• IDG stands for Interdisciplinary Group
• Core members include: RN, Hospice Physician, Social Worker, and Chaplain
• The team collaborates, oversees and makes decisions about the patient’s “Plan of Care” regarding physical, medical, psychosocial, emotional and spiritual needs
• IDG meets every 15 days or as often as necessary

• What does QAPI stand for? Quality Assessment Performance Improvement
• Does Hospice have a QAPI Program? YES!
• What are our current Performance Improvement Projects (PIPs)? Gaps in Nursing Care

1.) Pain Screening
2.) Pain Assessment
3.) Shortness of Breath Screening
4.) Shortness of Breath Treatment
5.) Opioid and Bowel Regimen
6.) Life Sustaining Treatment Preferences
7.) Spiritual Concerns

• Ensuring patients receive visits on two of the final three days of life from a nurse or social worker

Survey sent to the primary caregiver 2-3 months after patient’s death

CAHPS Quality Measures:
Communication with family
Getting timely help
Treating patient with respect
Emotional and Spiritual Support
Help for pain & Symptoms
Training Family to Care for Patient
*Consumer Assessment of Healthcare Providers and Systems

Indiana Department of Health


Where is a copy of our license located?
Framed and hanging at each location. (IPF by elevator)

Report the complaint to your supervisor.
Complete the “Patient/Family Complaint” form and submit to your suipervisor by next business day.
If the report involves abuse/neglect/misappropriation of patient property, report IMMEDIATELY to your supervisor.

Our Hospice does not discriminate on the basis of race, color, nationl origin, age, disability, or sex.
Our Hospice provides interpeter services for non-English speaking patients. Spanish Admission consents are available.

Patients have the right to formulate an Advance Directive if they desire.
At admission, patients recieve information on Advance Directives (“Your Right to Decide”).
Our Hospice staff can assist patients in completing an Advance Directives (POST, Health Care Representative, etc).
A patient does NOT have to be a DNR to recieve hospice services.

Patients have the right to choose an attending physician.
Patients may choose a Hospice provider to serve as his/her attending or may choose to not pick an Attending- in thise case Hospice serves as the Attending.

Patients have the right to a confidential health care record.
At admission, all patients choose a password. Patients only give the password to family/friends they wish to have health care information.
Who is our HIPAA Privacy Officer? Louis Townsend
Who is our HIPAA Security Officer? Angela Johnson

Patients have the right to be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, misappropriation of patient property, and corporal punishment.
Suspected/observed incidents need reported to your supervisor immediately.

  • Have property and person treated with respect.
  • Receive effective pain and symptom management
  • Be involved in developing plan of care
  • Be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff.
  • Restraint or seclusion will only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and will be discontinued at the earliest possible time.
  • Receive information about the services covered under the hospice benefit.
  • Receive information about the scope of services that OHSCI will provide and specific limitations on those services.