Policy pointers: Conducting an annual agency evaluation

HCPRO Website, January 21, 2013

Many agencies report survey citations because they did not conduct an annual evaluation of their program. The Conditions of Participation, §484.52, require a total program evaluation, consisting of an overall policy and administrative review and a clinical record review.

As with the professional advisory committee guidelines, the regulations are vague on how to structure this evaluation. One way to comply is to develop an effective policy for the annual program evaluation.
Some policy pointers include:
  • Define the purpose of the evaluation. The primary purpose is to ensure care that is appropriate, adequate, effective, and efficient. (Refer to the Interpretive Guidelines, §484.52, for definitions.)
  •  Identify a group of personnel to conduct the evaluation. Consider using the PAC—they are familiar with your agency's operations. Include a consumer representative, the administrator, and committee chairs.
  • Define the activities.
    • The evaluation committee must review fiscal, patient care, and administrative policies, as well as administrative practices, and conduct a record review.
    • The committee should collect and analyze data on topics such as case mix and adverse event outcome reports, staff and patient satisfaction, and processes and outcomes related to care.
    • The committee should evaluate the agency's mission, goals, and objectives; patient complaints; services provided under arrangement or at branches; personnel management; financial management; and/or information management.
    • The committee should also review recommendations from previous annual evaluations to determine the effectiveness of the activities.
  • Develop a schedule of activities. If the PAC conducts the evaluation, the schedule can distribute many of the required activities throughout the year. Develop a procedure and agenda for the evaluation. Assign a person to take notes.
  • Conduct a record review. The regulations do not define the exact type of record review. Buddy committee members with staff members to look at one or two records, focusing on the patient's needs, identified plan, and results. Also compile and share findings from record reviews conducted throughout the year.
  • Document the activities, including actions, recommendations, and decisions. The record should show that the committee evaluated the appropriateness, adequacy, effectiveness, and efficiency of care. Ensure follow-up actions by the administration and leadership of the agency.

By having a policy, you can ensure that you are in compliance with the CoPs.

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