The turn of the year is a natural reset point, and it's worth using that momentum for more than a resolution you'll forget by February. A deliberate look at your documentation and compliance posture before the new year starts is one of the most useful things a QA lead or DON can carve out time for, and it doesn't need to take more than a focused afternoon.

This isn't about finding everything that went wrong over the past year. It's about catching the specific patterns worth carrying a fix into the new year for, rather than starting January with the same quiet gaps still sitting in your process.

Here's the checklist worth working through.

Review your accuracy trends from the past year

Pull your OASIS, coding, and Plan of Care accuracy numbers from the past several months and look for a pattern, not just a snapshot. A single month of strong numbers can hide a slow drift that's been building underneath it. Compare accuracy across service lines specifically, since a strong overall number can mask a real weak spot in one area.

Check your ADR response readiness

Pull a handful of recent charts and ask honestly: if an ADR request landed on these tomorrow, would the documentation hold up without a scramble? Look specifically for whether medical necessity is clearly and individually supported on each chart, not just generally implied. This is the exact kind of gap that tends to surface only when it's already too late to fix quietly.

Look at your recertification and discharge documentation specifically

These two points in the episode carry outsized risk relative to how much attention they usually get. Recertifications are prone to timing errors, where a patient's status changed but the documentation didn't catch up. Discharge assessments are prone to being rushed since the clinical work already feels finished by that point. Both deserve a specific, deliberate check rather than getting folded into a general review.

Audit your secondary diagnosis coding for specificity

Pull a sample of charts and check whether secondary diagnoses are coded as specifically as the documentation actually supports, particularly further down the list where scrutiny tends to fade. An unspecified code sitting sixth or seventh on a chart is just as capable of costing an agency a comorbidity adjustment as one sitting first, it's just less likely to get a second look.

Check your LUPA thresholds against your actual case mix distribution

Pull a report of how many periods came close to or fell under a LUPA threshold over the past year, and look for a pattern rather than treating each one as an isolated case. A cluster of near-threshold periods in a specific case mix group can be a sign that functional scoring or comorbidity capture is quietly landing patients in a lower group than their actual acuity supports. Catching that pattern before the new year starts gives you a real head start on fixing it, rather than watching the same pattern repeat for another twelve months.

Review your functional improvement and discharge to community outcomes

These specific outcome measures depend on accuracy at both ends of an episode, the start of care baseline and the discharge assessment, and a gap at either point distorts the whole measure. A year-end look at how these outcomes trended, and whether any specific clinicians or teams show a consistent pattern worth addressing, gives you something concrete to work with heading into performance conversations for the new year.

Confirm your team is actually current on any regulatory changes from the past year

Between OASIS item updates, payment rule changes, and shifting audit priorities, it's easy for a change that rolled out mid-year to quietly stop being top of mind by December. A quick internal refresher on anything that changed keeps the team from carrying an outdated assumption into the new year.

Set a specific plan for what you'll actually track differently next year

A year-end review is only useful if it changes something. Pick one or two specific patterns from this checklist, whichever showed the clearest gap, and set a concrete plan for addressing them in the new year, rather than a vague intention to "do better" across everything at once.

Want help running this review

If you'd like a second set of eyes on where your documentation and compliance posture actually stands heading into the new year, we're happy to walk through it with you.