How to Fix Deficiencies Before They Happen
In home health and hospice, survey deficiencies aren’t just citations, they are symptoms. They often point to deeper issues in systems or daily operations. This is true when an agency is cited multiple times for one-two standards, citations for multiple standards or when a citation leads to potential patient safety issues.
Too often, agencies don’t act until something goes wrong. But the best performing organizations don’t wait for a deficiency to take action-they build systems that prevent them in the first place.
Deficiencies Don’t Start with the Surveyor
Deficiencies usually begin long before a state or accrediting body walks through your door. They start when:
Documentation is vague or inconsistent
On Site Supervisory oversight is inconsistent
Processes are built on assumptions instead of systems
Clinical teams don't fully understand the why behind the requirements.
If you’re only preparing for a survey when it’s announced, it’s already too late.
From Reactive to Proactive: How Leaders Prevent Deficiencies
Preventing deficiencies isn’t about doing more. It’s about doing the right things consistently. That starts with leadership owning the process and empowering teams to align with it.
Here are key actions you can take to shift from reactive to ready:
Conduct internal mock surveys
Regular internal audits using real survey tools help expose what’s missing before a surveyor does. Walk through your agency like a surveyor would; unannounced, objective, and detailed.
Use real-time monitoring tools
Don’t wait for a quarterly report to learn about a problem. Monitor high-risk metrics like missed, medication reconciliation gaps, individualized plan of care daily, week and as red flags arise.
Coach and Educate (Don’t just Remind)
Ongoing education and case-based learning help clinicians and coordinators understand what surveyors look for and why it matters to quality of care.
Audit Documentation for Intent
Is the documentation just checking a box? Or does it tell the clinical story, reflect coordination of care and align with care delivered as it is ordered.
Tie QAPI to Real Risks
Don’t choose random QAPI projects. Use actual audit findings, incident reports, complaint reports or patient outcomes to select QAPI focus areas that matter.
Building a Culture of Readiness
Compliance happens when leadership sets the tone.
When leaders model a proactive mindset and empower their teams to take ownership, survey readiness becomes part of the culture, not an emergency.
Your goal is to create an environment where:
Staff aren’t afraid of audits- they understand them
Processes are strong enough to hold up under pressure
Documentation defends care and reflects intent
Quality isn’t just a department- it is a shared responsibility
Want to Know Where Your Gaps Are?
Download our free Survey Readiness Tool- a clear, structured guide to help you evaluate your agency’s strengths and weaknesses, identify potential risk areas and take confident steps forward before your next survey.
Fixing deficiencies before they happen is possible-but it requires leadership, strategy and systems. When those are in place, survey success isn't luck. It’s intentional.