The CMS Survey Coordinator s Handbook Jeffrey T. Coleman
Table of contents About the author... iv Introduction... v Chapter 1: Know your surveyor... 1 Chapter 2: Know your survey... 5 Chapter 3: Know the Conditions of Participation... 13 Chapter 4: Know your role on survey day... 43 Chapter 5: Know what to do next... 47 Chapter 6: Know how to respond... 57 Chapter 7: Know the ambulatory surgery center survey... 61 Chapter 8: Know how to select a survey coordinator... 67 Chapter 9: Presurvey checklist for CoP compliance... 71 Case Study... 81 Appendix A: CMS Surveyor Guidelines for Determining Immediate Jeopardy... 89 Appendix B: CMS Ambulatory Surgical Services Interpretive Guidelines... 117 Appendix C: CMS proposed ASC Conditions of Participation... 139 The CMS Survey Coordinator s Handbook iii
C H A P T E R 1 Know your surveyor
C H A P T E R 1 Know your surveyor As survey coordinator, it is extremely important to understand the background and thinking of the surveyor or survey team when they arrive at your facility. Most surveyors come from state health agencies that contract with CMS to perform surveillance functions. Keep in mind that these individuals report to other state officials. That means you may have some recourse locally, which should be used if there are points of contention over survey findings. Don t call your regional CMS office over a disagreement in regulatory interpretation until you have exhausted your efforts at the state level. In some cases, you may find that the survey is being conducted by CMS itself. This is CMS choice, and often may happen if: State resources are limited There is a specific complaint that interests CMS CMS audits state survey findings Yes, CMS will survey a facility after state representatives have conducted a survey themselves. Although groans may arise from administration over this, it is vitally important to be on your guard if this specific situation occurs. It is within the purview of CMS to audit its state surveillance agencies (a look-behind survey). If this does happen, it may be a simple quality assessment of the state surveillance process. As sometimes happens, state surveyors may be accompanied by CMS representatives in a joint survey process. In any event, it is important to understand that surveyors may be influenced by the other surveys they conduct. The CMS Survey Coordinator s Handbook 3
Chapter one Survey staff may have a very wide range of surveillance experience. They are often called upon to be generalists, covering all types of CMS-required surveillance from long-term care, home health care, renal dialysis centers, and, of course, acute care. Each variety of CMS-certified entity mentioned above has its own unique survey characteristics and requirements. In addition, the emphasis placed by CMS on those areas may transfer over to your hospital survey. It should not, but make sure you re knowledgeable about the CoPs and especially the Interpretive Guidelines that direct the surveyors. Although the surveyors may not have had recent (or any) acute-care experience, they have the Interpretive Guidelines to follow. Making yourself readily available to surveyors to answer questions or clarify their questions may prevent misinterpretation of hospital practices. Any hospital with a skilled nursing facility that is surveyed under the CoPs for long-term care will understand the dramatic difference between the two surveys. Long-term care is very prescriptive, and oriented toward certain specific outcome measures. For example, occurrence of decubitus ulcers and urine odor are two red flags for surveyors, and may lead to imposition of an immediate jeopardy as well as the possibility of losing Medicare reimbursement to the facility. In the case of survey processes involving the Life Safety Code (LSC), state surveyors are usually certified by CMS. In some states, the state fire marshal s representative conducts this portion of the survey. They may or may not have acute-care exposure with reference to these surveys. In any event, your facilities management staff should be prepared with the following: Any architectural drawings or plans for the hospital (or Statement of Condition in a Joint Commission-accredited hospital) The plans should clearly indicate smoke compartments and locations of exits If changes have been made to the facility structure, drawings should be available for those as well Remember that the majority of deficiencies found on CMS surveys are found in the life-safety and environmental areas. Preparation for and involvement in the survey process will be critical for those department heads. 4 The CMS Survey Coordinator s Handbook
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