Surveyor Worksheets

2197 – Surveyor Worksheets (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The following surveyor worksheets are used during each home health survey to assist the surveyor’s determination of the agency’s compliance with the home health conditions of participation. HHA Survey Investigation Worksheet 1 – Patient Sample: Complete one patient sample investigation worksheet for each patient record and home visit selected. Use the worksheet to collect and record patient information and findings related to record review and home visit information to determine the appropriateness of care or services being furnished. Note interviews with clinicians, record review findings and observations. In addition to completing the worksheet, it may be appropriate to request the HHA to copy the most current plan of care for each patient in the survey sample that identifies baseline medical information for attachment to the patient’s worksheet. Additional documentation, including assessments, medication profiles, visit notes, aide plans or orders may be copied to support findings. Complete each section with comments related to potential tags identified or indicate “Not Applicable/NA.” HHA Survey Investigation Worksheet 2 – Agency Summary: Use the survey investigation worksheet 2 to record a summary of any deficient practices identified during the survey. Also record the type of survey(s) performed, the number of agency admissions in the previous 12 months as well as the number of records reviewed and home visits completed. HHA Survey Investigation Calendar Worksheet: Use the Calendar Worksheet to determine compliance with §484.18(a) and (b) and §484.55 regarding compliance with orders for service and the findings of the comprehensive assessment. Services ordered can be compared to services provided to determine compliance with visits.