Provided below are several reports the Surveyor will request during your on-site Accreditation Commission for Health Care (ACHC) Home Health Accreditation Survey.
Patient-related reports are just a few of the reports needed for your survey. These reports assist the Surveyor in choosing the medical records and home visits that will be reviewed.
You should be ready and able to run the reports that are listed below, along with any others that might be needed. Contact Ace Compliance Consulting for training and support in generating these reports.
Unduplicated Admissions Report
- This is the list of each individual patient who has been admitted to the agency one time in the past 12 months or since the start of business, regardless of the payor.
- For agencies seeking a recommendation for deemed status (Centers for Medicare & Medicaid Services Medicare certification), the number of unduplicated admissions determines the number of medical records and home visits required to be completed for the survey to be valid.
- 300 or fewer admissions: 7 total record reviews
- Minimum of 2 active record reviews without a home visit
- Minimum of 3 record reviews with a home visit
- Minimum of 2 closed record reviews
- 301 to 500 admissions: 10 total record reviews
- Minimum of 3 active record reviews without a home visit
- Minimum of 4 record reviews with a home visit
- Minimum of 3 closed record reviews
- 501 to 700 admissions: 13 total record reviews
- Minimum of 4 active record reviews without a home visit
- Minimum of 5 record reviews with a home visit
- Minimum of 4 closed record reviews
- 701 or more admissions: 17 total record reviews
- Minimum of 5 active record reviews without a home visit
- Minimum of 7 record reviews with a home visit
- Minimum of 5 closed record reviews
- For agencies not seeking a recommendation for deemed status, the Surveyor will perform at least 7 medical record reviews and 3 home visits.
- This list of active patients who are currently receiving services helps the Surveyor determine the specific medical records chosen for review. The information on the list should include each patient’s name, admission date, and primary diagnosis, along with the disciplines providing care to the patient.
Schedule of Visits Report
- This report is used to determine the specific home visits that will be conducted during your survey.
Discharged Patients Report
- This report should list the patients who have been discharged from the agency in the past 12 months, including patients who were discharged or transferred to another health care provider. The information on the list should include each patient’s name, admission date, and discharge date. This will be used by the Surveyor to choose closed medical records for review during the survey.
OASIS Validation Reports
- Applicable to surveys of Medicare-certified agencies, these reports are used by the Surveyor to determine if specific medical records will be reviewed based on the Outcome and Assessment Information Set (OASIS) validation reports.
- The Surveyor will need to access the most recent 12 months of each of these three reports:
- Risk-Adjusted Potentially Avoidable Event Report
- Potentially Avoidable Event Report: Patient Listing
- Agency Patient-Related Characteristics Report
For more information on OASIS validation reports, visit here.
Tips for Compliance
- Practice running each report to ensure the correct information can be provided to the Surveyor on time.
- If you are unfamiliar with how to run these reports, contact your software vendor before the survey.
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