From Deficiency to Accreditation: Real-World Examples of Agency Turnarounds

In the heavily regulated world of home health and hospice care, compliance is not optional—it is the backbone of safe, ethical, and legally compliant patient care. But for many agencies, survey deficiencies can feel overwhelming. Receiving a Statement of Deficiencies (2567), a failed survey, or a condition-level citation puts an agency at immediate risk: halted admissions, payment suspension, increased scrutiny, state follow-ups, and potential termination from Medicare.

However, deficiency does not have to be synonymous with failure. In fact, many of the most successful home health and hospice agencies today once faced severe operational or clinical compliance issues before transforming their systems and achieving full accreditation.

This article explores real-world examples of agency turnarounds, highlights what went wrong, how issues were corrected, and what steps led to successful accreditation—while aligning closely with the Medicare Conditions of Participation (CoPs) for home health and hospice.

Understanding Deficiencies: Why They Occur

Deficiencies arise when a surveyor identifies that an agency is not meeting a federal CoP or a state licensing requirement. Common triggers include:

• Incomplete clinical documentation

• Failure to meet timeliness standards

• Incomplete or missing comprehensive assessments (e.g., §484.55 for home health)

• Lack of documentation showing decline for hospice

• Missing care plan updates or IDG documentation

• Improper supervision of LVNs, HHAs, or CNAs

• Missing emergency preparedness plan elements

• Inaccurate or incomplete QAPI program

• Noncompliance with personnel file requirements

While deficiencies may vary, the solutions often follow predictable patterns: analysis, correction, prevention, and documentation.

Case Study 1: Home Health Agency with Condition-Level Deficiencies

The Situation

A medium-sized home health agency in California failed its state survey due to multiple condition-level deficiencies, primarily involving:

• Late or incomplete comprehensive assessments (§484.55)

• Missing OASIS documentation

• Care plans without updates reflecting changes in condition

• Poor coordination between RN, PT, and MSW services

• QAPI program with no measurable performance indicators

The agency was placed under immediate jeopardy of losing its Medicare certification.

The Turnaround Strategy

1. Rapid Assessment of All Clinical Documentation

A full audit was performed on:

• SOC/ROC/Recert visits

• OASIS accuracy

• Care plans

• Supervisory visits

• Coordination notes

This audit revealed systemic delays, inconsistencies in assessment completion, and multiple non-billable episodes.

2. Redesign of RN Workflow

To comply with CoPs, the agency implemented:

• Timed SOC → OASIS workflow protocols

• Immediate cross-discipline communication templates

• Daily clinical huddles for care plan alignment

These changes ensured compliance with §484.60 (Care Planning, Coordination, and Delivery of Care).

3. Strengthening the QAPI Program

Surveyors specifically noted “QAPI in name only.”

The agency built a legally compliant QAPI program with:

• Quarterly measurable indicators

• Data-driven performance improvement cycles

• Documentation of actions taken—not just problems identified

4. Staff Retraining and Competency Validation

All field staff underwent mandatory retraining covering:

• OASIS documentation

• Timeliness standards

• Nursing process

• Infection control

• Coordination notes

Competency check-offs ensured accountability.

The Result

Within 60 days, the agency submitted a strong Plan of Correction (POC) with:

• Corrective actions

• Preventive measures

• Monitoring tools

• Responsible personnel

A focused revisit survey confirmed compliance, and the agency achieved renewed accreditation without penalties.

Case Study 2: Hospice Agency Facing Immediate Jeopardy

The Situation

A hospice agency in Southern California received an Immediate Jeopardy (IJ) citation after surveyors found:

• Missing CTI (Certification of Terminal Illness) elements

• Incomplete IDG documentation

• Notes lacking objective evidence of decline

• Medications without associated diagnoses

• Missing RN supervisory visits

Failure to demonstrate eligibility under §418.22 and §418.56 put the agency’s Medicare identity at risk.

The Turnaround Strategy

1. Complete Clinical Documentation Overhaul

A team of nurse auditors reviewed:

• CTIs for both physician certification statements and detailed narratives

• Face-to-face encounter documentation

• IDG interdisciplinary group compliance

• Plan of care updates

• Medication reconciliation

The team identified several issues:

• Physicians were using template CTIs lacking specificity

• Decline was not documented in measurable terms

• The IDG was not clearly revising the POC every 15 days as required

2. Retraining Medical Directors and IDG Physicians

The hospice’s physicians were trained to write:

• Condition-specific clinical narratives

• Objective measurements of decline

• Clear prognostic indicators

Examples were provided for dementia, CHF, COPD, cancer, and stroke.

3. New IDG Documentation Workflow

The hospice implemented:

• Pre-IDG clinical summaries

• Real-time POC updates during the IDG

• Documented medical necessity for all interventions

• Team communication protocols

This ensured compliance with §418.56 and §418.58.

4. Strengthening RN Supervision

The agency created:

• Supervisory visit tracking sheets

• Automated reminders

• A supervisory visit audit log

This prevented future missed visits.

The Result

In just 30 days, the IJ was removed.
In 90 days, the hospice passed a federal validation survey with zero condition-level deficiencies.

It is now a referral-rich, fully accredited agency known for exceptional compliance.

Case Study 3: Startup Agency That Failed Its Initial Survey

The Situation

A new home health agency attempted its initial survey and failed due to:

• Missing policies required under CoPs

• Incomplete personnel files

• An emergency preparedness plan that did not meet federal standards

• Governing body minutes missing approvals

• No measurable QAPI indicators

• Inconsistent orientation records

The survey ended early and the agency was required to re-apply.

The Turnaround Strategy

1. Development of a Complete Policy & Procedure System

The agency received:

• Fully CoP-aligned policies

• Updated emergency preparedness templates

• Staff education modules

• Governing body templates

• Contracted provider agreements

Each document was customized to match the agency’s service model.

2. Personnel File Reconstruction

Missing items were corrected:

• TB/PPD results

• Licenses and certifications

• Job descriptions

• Signed competency checklists

• Orientation records

• Mandatory in-services

An HR file audit tool was implemented to prevent recurrence.

3. Operational Readiness Training

Leadership underwent training on:

• Daily operations

• Intake and admission procedures

• Clinical coordination

• Compliance monitoring

• Survey preparedness

4. Mock Survey

A full mock survey with tracer patients was performed, identifying and correcting the final issues.

The Result

On the second attempt, the agency passed the survey with no condition-level findings, received its license, and successfully enrolled in Medicare.

It now operates at full capacity with clean compliance records.

How Agencies Can Prevent Future Deficiencies

Successful agencies do not wait for a survey to find problems—they build systems.
Key strategies include:

1. Routine Clinical Record Reviews

Regular audits ensure compliance with:

• Medicare CoPs

• OASIS accuracy standards

• Eligibility documentation

• Timeliness of assessments

• IDG documentation

• POC revision requirements

2. Strong QAPI Program

A functional QAPI program must include:

• Quarterly measurable goals

• Performance improvement projects

• Documentation of corrective actions

• Follow-up evaluation

3. Mock Surveys

Mock surveys simulate real surveyor behavior, identifying issues early.

4. Up-to-Date Policies

Policies must match:

• Current federal CoPs

• State licensing requirements

• CMS updates

• Emergency preparedness rules

5. Staff Education

Annual and ongoing training helps maintain:

• Documentation accuracy

• Infection control

• Patient rights compliance

• Discipline-specific competency

Conclusion: Deficiency Does Not Mean Failure—It Means Opportunity

Every agency in the examples above started from a position of deficiency—some with severe findings, others with operational gaps—but each achieved full accreditation through:

• Structured corrective action

• Strong documentation

• Leadership training

• Clinical oversight

• Expert guidance

The reality is that most agencies can recover, but only with the right support, clear systems, and consistent follow-up.

Need Help Bringing Your Agency From Deficiency to Accreditation?

HealthBridge Consulting specializes in:

• Deficiency correction

• POC development

• Mock surveys

• Clinical documentation audits

• QAPI program development

• Operational restructuring

• Accreditation readiness

• Ongoing QA/oversight

Whether you are facing a survey, recovering from a failed one, or preparing for accreditation, HealthBridge ensures your agency remains compliant with all Medicare Conditions of Participation and state licensing requirements.

Your turnaround story can begin today.
For full-service consulting and clinical compliance support, partner with HealthBridge.