I’m from CMS and I’m investigating an event . . .
This is the third part of a four part series on CMS Survey experience and lessons learned. Click here to download a PDF containing all four articles in the series.
Part III – Managing a CMS Licensing Survey
Your organization has experienced a sentinel event which has triggered a response from regulatory and accrediting agencies. As the survey coordinator, nursing leader, operating officer or quality professional, you have already welcomed the State Department of Health in to investigate the situation, may have communicated with The Joint Commission regarding the root cause analysis that is underway, and now, representatives from the Centers for Medicare & Medicaid Services (CMS) have arrived to conduct a full licensing survey. This may have been warranted based on the severity of the initial event and/or the organization’s response to that event.
What to Expect
Regardless of the sentinel event that initially triggered the CMS visit, all Conditions of Participation will be scrutinized during a full licensing survey. Clinical and physical environment surveyors will be onsite for days, if not weeks, at a time. The surveyor cadre will vary depending on the scope, size and complexity of both the organization, the services provided under the CMS Certification Number (CCN), and the initial concern that earned CMS attention. It will minimally include nurse surveyors, life safety surveyors and possibly pharmacists, dieticians or sanitarians, depending on the issue. Organizations that have experienced such surveys have had a CMS survey team onsite for up to six weeks.
How Can You Manage the Survey?
While CMS surveys are somewhat different than the TJC surveys, most of us have developed survey response plans that will be very helpful in managing a full CMS survey. If you haven’t done this, create a survey response plan now that will assist you in rising to the occasion for any unexpected surveyors. Some helpful hints in preparation include:
1. Establish a headquarters for the CMS survey team. Provide writing space, phone lines and access to electrical outlets. Note that most government employees are not permitted to accept food without payment. You may offer coffee and water.
2. Establish an internal command center to manage survey activities. Depending on length and scope of survey, staffing this command center may require some flexibility. However, it can be used to:
a. Serve as a conduit between CMS surveyors and organizational staff
b. Receive updates from survey activity to track potential deficiencies
c. Coordinate activities to rectify, when possible, identified deficiencies
d. Centralized resource for requested documents, policies, procedures, etc.
e. Use CMS Interpretive Guidelines to assist staff in managing survey process and understand surveyor expectations
f. Communicate hot issues to the rest of the organization to mitigate additional scoring
3. Assign an internal escort to each member of the survey team. It is particularly helpful to have pre-existing policies that outline the organization’s requirement that any external agency representative be escorted by a member of the hospital staff.
4. Provide CMS survey team with requested documents as quickly as possible. Based on recent CMS survey experiences, a comprehensive list of documents, policies, procedures, plans, testing logs, etc., will be requested at the outset of the survey. Please click on this link to access a sample list.
5. Regularly hold internal debriefing meetings to advise management how the survey is going, to identify deficiencies that may be cited, and to begin the arduous task of responding to deficiencies with corrective actions.
CMS survey reports have the potential to include numerous environmental deficiencies as well as clinical concerns. Each one must be addressed individually. Thus, it is extremely helpful to have both clinical and environmental teams staying on top of surveyor findings but also beginning to develop corrective action plans.
In Summary
Full CMS surveys warrant significant internal resources, both during the survey and during the post-survey response process. One organization told us they felt like they had lost six months from the time of their event until the CMS corrective actions were implemented. Having an organizational understanding of the Conditions of Participation, and integrating requirements into organizational policy, process and practice will assure a greater state of readiness should you experience a CMS survey. Actively managing the survey process and engaging with the CMS survey team in a professional and collegial manner will provide a more comfortable atmosphere for the survey team and organizational staff alike.
See a future edition of C&A News for the last in this series, Part IV – Responding to Findings from a CMS Licensing Survey. Click here to download a PDF containing all four articles in the series.