Cindy Firme, RN, PHN (center of above photo) recently shared with Champ Software that Renville County Public Health’s Home Healthcare department received a successful home care survey by CMS in November 2017.


Cindy has been a Public Health Supervisor with Renville County Public Health for 30 years. Renville County is situated just southwest of the Minneapolis-St. Paul metro area in Minnesota and boasts a population of a little under 15,000.

Renville County Public Health was established in 1916 and established a Medicare-certified and Minnesota Department of Health licensed home care agency over 40 years ago. Renville County Public Health’s home care workers see an average of 54 unduplicated home health clients per quarter, handling around 6 to 10 Medicare cases at any given time, sharing the work between 5 staff.

“That sounds busy!” we said, and Cindy replied, “It’s a lot. We’re comparable to any of the private agencies in the area. Maybe even a little busier… even though I’m the supervisor, I also carry a caseload. But I think that’s good. The supervisor having a caseload – you know exactly what your staff are going through. It’s a tremendous amount of documentation.”

The home care services Renville County provides cover a wide range, including skilled nursing, home health aide, and therapy (e.g. physical therapy, occupational therapy, speech therapy) in the patient’s home.

“[The Medicare cases] are the really intensive cases, where you need the face to face documentation. They have all the therapy. If the home health aide goes in, we have to do an every two-week RN supervision of the home health aide. But the bulk of our home visiting is the long-term, chronic cases, mostly mental health cases. We do a lot of medication management,” shared Cindy.

What happens during CMS surveys?

Medicare (or CMS) Surveys happen every three years. However, they are unannounced. When surveyors come, “There is a standard based on your census for what your surveyor looks at,” Cindy shared, “The surveyors typically look at 5 client files in addition to 5 home visits from all disciplines and review those records. They also do staff interviews.” While surveyors are there, they get access to Renville County’s electronic health record (EHR), Nightingale Notes so they can look at everything. “You’re never quite sure what they’ll scrutinize. It’s unpredictable. I just try to learn from the previous years,” Cindy said. When asked how she prepares her agency for these surveys and what tips she could share for other agencies wishing to prepare for a successful CMS survey, Cindy shared the following:

Have Your Reports Ready

Be aware of what information the surveyor will want and be ready to run those reports

“My biggest tip is to make sure you have your reports built,” Cindy said emphatically. “The surveyors want specific things such as the number of unduplicated admissions in the last twelve months, or the current caseload with diagnosis and discipline (which means, do they have skilled nursing, home health aide and therapies, or what do they have?). They want those reports the minute they walk in the door.”

Make use of a staff member who can build reports and who knows those reports inside and out

“Make sure, if you’re not the builder of reports, that you have someone who really understands report building,” Cindy recommended.

Practice running the reports multiple times until you feel really confident about them

“Practice the filters for the time frame so that the reports come out correctly. We had done that multiple times. Our accountant and I do those,” she shared.

Mark the reports you know you’ll need for the CMS survey, so they are easy to find

Cindy and her team placed an asterisk next to those reports on the reports page, so they could quickly find the necessary reports.

Know Where to Find Things and Be Organized

Be consistent

Cindy shared about some issues her agency had with consistency in how they were scanning things into Nightingale Notes EHR, “One person would keep things on paper and one person would do it electronically; then you have trouble because it’s not consistent… Ensure each of your clinicians is doing it the same way.”

Know where things are documented

“It’s also critical that you understand as an agency where things are documented,” Cindy said. “That’s the key. Surveyors will love it if your files are organized.” During her survey she made sure she knew where everything was documented and could print anything needed and hand it to the Surveyors right away without a struggle. “That can cause stress if you aren’t prepared,” she said.

Create an organizational cheat sheet of where to find everything

“I did a document on our format, where you can find everything. Our home health aides do paper documentation and we scan all that in. The way the paper charts are set up is how I have the categories set up in the file tab. Things on page one in the paper chart are found in category one under the files tab… When the Surveyors come, I can give them that organizational cheat sheet and say, ‘This is where you’ll find things.”

Cindy went on to share how much it helped her agency to have everything organized and to be able to show the Surveyor where everything was, so they didn’t have to search for anything, “That’s what they were most impressed by; we have it nailed down… Everything is logically placed so they know where to find it.”

Conduct Peer Reviews

Ask a third-party to review your agency

A fresh, third-party perspective can help staff “get” something they weren’t understanding before. While Cindy acknowledges that distance can be an issue when asking another agency to “audit” yours, and that it can feel threatening to have someone else look at your work, she also points out how beneficial it can be.

“I may have said something five times, but then when someone from outside the agency comes in to say it, suddenly the staff thinks, ‘Oh- that’s what you mean!’ It’s amazing how that happens… It’s almost a best practice to have an outside agency come in.” Another benefit is that a fresh pair of eyes will often see something that might have been missed before.

Consider partnering with another agency to give each other checkups

“I used to do it with another home care agency. When Redwood County was a home care agency, I’d go there and do their chart audit and they’d come here and do ours, but then they got out of home care.” Such a partnership can be mutually beneficial and help both agencies feel well-prepared for Surveys.

Have your own staff review each other as well

“I don’t think it’s helpful for only one person to be doing the chart audit. So, we’ve moved it to a peer review. Everyone knows what the Surveyors will look for and we peer review each other’s files. Quarterly I run a caseload report. I try to choose primarily our new Medicare admissions and then we review those individually and try to look at trends.”

Cindy also looks for consistency to ensure all clinicians are doing things the same way. “You can have your own practice, but we need to be consistent with how we’re doing things.”

Prepare Your Staff

Conduct mock audits to help your staff prepare for Surveys

“Every quarter I run a case-load report and I run a mock audit. We look at our most recent Medicare admissions. Medicare surveys are unannounced. You need to be survey-ready all the time.” She added, “We have a chart review form that’s about 4 pages long and hits all the things required. We do it quarterly.”

Prepare your staff to answer any questions a Surveyor may ask

“I have a cheat sheet I’ve made for staff to be aware of potential questions Surveyors might ask. You need to groom and prepare your staff. There’s no two ways about it; it’s stressful – I get just as stressed as the next person. But if you are prepared, if you know where to find things, if you know where to find your policies, if you know how you have it organized and where you’re going to find everything in your software – the Surveyors can tell if you know what you’re doing as an agency or if you’re just stumbling along.”

Be aware of who can perform well under pressure

“The [Surveyors] will interview your staff. If you know your staff who can handle pressure, help those staff be ready to be interviewed,” Cindy offered. “The manager and administrator are always interviewed no matter what. But if you know which staff can handle pressure, help prepare them.”

Ensure your staff is well-versed in how your agency organizes everything and is adhering to that structure

“Make sure everyone can find everything. I keep a record of where [staff] can find everything. The key is – do peer review so you all know where everything is. If someone is looking at my files and they should be able to find everything. If they can’t, do your QI to get it where it should be. Continue to monitor it,” Cindy recommends.

Stay Up to Date with the CoPs

Know when regulations change

Conditions of Participation (CoPs) are rules an entity has to adhere to in order to meet Medicare and Medicaid regulations. Cindy explained, ““There are 14 CoPs, and they’re changing as of January for the first time in 30 years.” Renville County’s CMS Survey was completed in November, just before the changes. “Now that [the CoPs] are changing, we don’t really quite know what we’re going to be surveyed for.”

Educate yourself so you fully understand those changes

Cindy’s solution? “You have to keep educating yourself,” she said. She and her staff take advantage of free trainings and educational opportunities to stay abreast of changes in CoPs and the most current standards.

Join an Organization

Find a network of support

Another tip Cindy offered was to join an organization. “It’s really important to belong to an organization such as the Minnesota Home Care Organization. We belong to them. We have regional meetings. We help keep each other front and center. You have to.”

Create a network of resources

“We share forms,” Cindy said about the Minnesota Home Care Organization. “I have no problem sharing whatever pathway people want. We built a vulnerable adult custom tab. Now we have it in Nightingale Notes and it’s right there for us.”

She continued, “I don’t have a problem at all sharing intervention pathways with our counterparts, which are mainly [Des Moines Valley Health & Human Services], Le Sueur County, and Brown [County]. They all do home care with Nightingale Notes.”

How does Nightingale Notes EHR fit in?

We asked Cindy what impact Nightingale Notes has on her agency’s ability to receive a successful CMS Survey. The biggest impact for Cindy has been Champ Software’s responsiveness when her agency has needed changes in the software.

“Champ has really responded to what our needs are, with some of our new Conditions of Participation that are needed… I know there’s been a lot through the years with all the OASIS changes (which is the data set we transmit to CMS) and changes from ICD-9 to ICD-10, but [Nightingale Notes] is always ready to go and we always have the instructions on what we need to do and when we need to do it.”

A specific example was the Medication Administration Record (MAR) tool that was built into Nightingale Notes.

“We pushed so hard for the electronic MAR to be built into Nightingale Notes… The [Surveyors] believed that even though we aren’t facilities (we see people in their homes) we had to have a medication administration record just like they do in a nursing home or hospital… A group of us met with Norah [Savard from Champ] last summer to see, ‘How can we build a MAR into Nightingale Notes?” Cindy explained.

We asked Cindy whether she felt she had a voice in the discussion on how the feature was designed and whether she felt her ideas were implemented. “Absolutely!” she said. “We did a face to face meeting in Mankato last summer. We were all there:  Darlene from LeSueur [County], Kayla from Brown [County], Allison from [Des Moines Valley Health & Human Services] and we all brought staff.”

How is the tool working out for Cindy and her agency? “We were looking forward to the drug interactions in Nightingale Notes and that’s there now… it’s a big time-saver for our staff. We can eliminate all that paper and just get back to just documenting electronically.”

And how does Cindy feel about Nightingale Notes EHR?

“It meets all our needs related to the requirements for home care. Champ is receptive to any and all recommendations for enhancements to meet the ever-changing regulatory burden of home care.”

Cindy Firme, RN, PHN, Public Health Supervisor with Renville County Public Health
Nightingale Notes customers meet to discuss MAR feature in Nightingale Notes

Cindy (far right) and representatives from a group of Minnesota counties meet to discuss adding the MAR feature to Nightingale Notes, Summer 2017


We’re so grateful Cindy took the time to share her story with us and to offer some tips on how to have a successful CMS Survey. If you want to learn more about Nightingale Notes, you can Contact Us at (507)-388-4141.