The CMS Survey Guide Jeffrey Jeffrey T. T. Coleman Coleman
Contents About the Author......................................................... v Introduction............................................................ vii Pre-survey Checklist for CoP Compliance....................................... xi Chapter One: Types of CMS Surveys........................................... 1 Chapter Two: The Current CMS Survey Process................................... 7 Chapter Three: Tips on CoP Compliance....................................... 15 Chapter Four: The CMS Ambulatory Surgery Center Survey Process................... 49 Chapter Five: What to Expect After the Survey.................................. 61 Appendix A: CMS Surveyor Guidelines for Determining Immediate Jeopardy............. 73 Appendix B: CMS Ambulatory Surgical Services Interpretive Guidelines............... 117 Related Products from HCPro.............................................. 143
C H A P T E R O N E Types of CMS Surveys
Chapter One Types of CMS Surveys As with any accreditation program, the Centers for Medicare & Medicaid Services (CMS) survey process includes both planned, or targeted, surveys and unannounced surveys based on compliance issues that need investigation. As of May 2004, all CMS hospital surveys are unannounced. The following types of surveys are most commonly conducted using the Conditions of Participation (CoP): Full survey As its name implies, this type of survey uses CoPs to conduct a full evaluation of the facility. Such surveys are reserved for hospitals that lack accreditation. The state agency or CMS will schedule each within the CMS fiscal year, but your facility will not be made aware of the survey dates assigned to it. Note that unaccredited hospitals can expect to be surveyed every three years; hospitals being surveyed following non-accreditation can be surveyed as soon as 30 60 days after the date on which non-accreditation status becomes effective. Sample validation survey Commonly considered a look behind survey, this type is either a full survey of an accredited hospital or a partial survey that focuses on designated CoPs. State agency surveyors are only in the facility to determine hospital compliance with the CoPs
Chapter One they do not need to see or hear a report on what problems or issues the accrediting surveyors found. Sample validation surveys often surprise accredited facilities because they usually are conducted within the 60 days (and soon to be 30 days) immediately following the accreditor s survey. But their purpose is not necessarily to compare the accrediting agency s findings with CMS CoP compliance. Rather, their primary purpose is to help CMS determine whether accrediting bodies effectively identify deficiencies in hospital operations and effectively monitor corrective action. Each year, approximately 1% of accredited hospitals are selected to undergo them. In response to a critical Office of Inspector General report in July 1999, CMS has increased the number of sample validations it performs. It has also reinstituted a midcycle validation of accredited hospitals starting at the 18-month period immediately following the accreditation survey. Because the JCAHO is making its surveys unannounced, these sample validation surveys may now be a little less troublesome. But keep in mind that the 30-day period following completion of the accrediting agency s survey is when this sample validation most likely will take place. The 18th month following an accrediting survey also bears watching. Allegation survey Allegation surveys can address one or more (and possibly all) of the CoPs and occur most often in response to complaints filed with the federal government against a facility. Such a complaint can be a letter or call to an elected or appointed federal representative from a constituent, or it can be an anonymous complaint from any source. It can be referred by Quality Improvement Organizations (QIO), formerly known as peer review organizations. It also can be referred by state agencies who then receive a directive from CMS to perform a survey.
Types of CMS Surveys Complaints do not have to involve Medicare or Medicaid recipients for a survey to be initiated. Any complaint, regardless of the complaint s source of insurance or lack thereof, may be investigated. After receiving the complaint, CMS reviews it, categorizes the allegations regarding alleged misconduct, and compares the allegations to the CoPs. CMS staff then select the most applicable CoPs and send a request to the state agency for a survey of those CoPs. Emergency Medical Treatment and Labor Act (EMTALA) surveys are a type of allegation survey, and may involve not only review of compliance with the EMTALA CoP, but also the Emergency Services and Quality Assurance and Performance Improvement CoPs, to name two possibilities. In addition to complaints, another trigger for an allegation survey may be negative publicity. Media reports of an untoward event, rumors of financial insolvency, or problems with another federal agency (such as the Department of Housing and Urban Development, the Internal Revenue Service, or the Drug Enforcement Administration), may ultimately find their way to CMS and result in a survey request. Distinct units CoPs exist for acute care, certified rehabilitation, or psychiatric units for which Prospective Payment System (PPS) waivers have been granted by CMS. In years past, state agencies were obliged to survey these units annually for compliance with the applicable CoPs. More recently, however, facilities complete an annual self-attestation of compliance, and no onsite survey is conducted. But CMS may pick a sample of these units to be surveyed every year. As of 2004, facilities that are selected for a full validation survey will automatically have the distinct unit(s) CoPs reviewed for compliance by the survey team. This means that those units, which used to remain fairly untouched during a validation survey or full survey, will be reviewed extensively. The only exception to this distinct unit survey policy occurs if the survey time frame falls within 90 days of the end of the federal cost reporting period.
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