Case Study: Survey Deficiency Correction

Drug Diversion

As of September 2014, California Department of Public Health (CDPH) issued 14,990 deficiencies to 2,288 long term care facilities from surveys for fiscal year 2013‐2014. CMS’ 2012 Nursing Home Action Plan explained that facilities rarely address the underlying systematic problems that give rise to repeated cycles of deficiencies. The Office of the Inspector General (OIG) for the Department of Health and Human Services (DHHS) identified oversight of poorly performing nursing homes as one of their focus areas starting in 2013. Specifically, the OIG intends to increase oversight of the state survey process to ensure that state agencies follow up with nursing homes to monitor the implementation of plans of correction.

A skilled nursing facility requested that an audit in regards to survey deficiency correction. The audit was designed to assist the facility in identifying trends in deficiencies issued as a result of both standard and complaint surveys over the past three years. 

Compliagent’s Actions: Compliagent’s Senior Clinical Consultant conducted an onsite audit and requested copies of all standard and complaint survey from the past three years to present for trending analysis. Subsequently, all deficiencies were trended for reoccurrence over the past three year period and categorized to illustrate areas for improvement within the facility’s operation. Throughout the investigation, Compliagent determined over 20 different citations for deficient practices and several citations from the recertification survey. Prior to exiting the facility, Compliagent provided several recommendations and best practices to the facility in order to reduce the number of deficiencies, come survey. 

Outcomes: After implementing Compliagent's recommended actions and best practices cited in the audit memorandum, the facility underwent survey and were able to drastically reduce the number of deficiencies cited. The facility staff was confident in their improvement and now have the tools to continually advance their quality of care and administration.

“Compliagent’s team was extremely effective and efficient in their audit, identifying areas of improvement and recommended corrective actions in order to meet best practices and ensure compliance. The audit was thorough, comprehensive, and professionally conducted. And the knowledge we gained from the audit will help us greatly in the years to come.”


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