I’m from CMS and I’m investigating an event . . .
This is the fourth and final article in a series on Centers for Medicare & Medicaid Services (CMS) survey experiences and lessons learned. If you missed the first three articles in this series, click here to download a PDF containing all four articles.
Part IV – Responding to Findings from a CMS Licensing Survey
You’ve experienced your first (or fourth) full blown CMS licensing, or certification, survey. In the first three articles of the series, we’ve talked about the sentinel event that may have led to this survey. Or, you could have experienced a random validation survey. In any event, the survey is over and you are awaiting the final report of deficiencies. But you are not waiting to implement corrective actions!
The report of deficiencies, identified on CMS Form 2567, may come days or weeks after your survey. However, once the report arrives you will have only 10 calendar days from the date of receipt to submit your plans of correction. So it is important to begin to develop and implement plans of correction prior to receipt of the 2567. Preliminary response planning should include:
- Addressing any environmental and Life Safety deficiencies identified.
- Reviewing policies and procedures related to issues identified during the CMS exit briefing or throughout the survey. Begin the revision and approval process.
- Refer to CMS Conditions of Participation and related standards of The Joint Commission (TJC) when revising policies and procedures.
- Develop performance monitoring systems to assure ongoing adherence to CMS requirements for those identified deficiencies.
Once the official report of deficiencies arrives, review the cover letter and report to learn the level of the deficiencies and the required components of your response.
- Immediate Jeopardy – a situation that posed immediate threat to the health and safety of patients was identified during survey. This would have been addressed during survey; however, it must still be responded to on the 2567.
- Condition Level – one or more Conditions of Participation were found to be out of compliance and the organization faces termination of its participation in the
- CMS program if acceptable plans of correction are not implemented. During a resurvey at 45 days, the organization will be expected to be in complete compliance.
- Standard Level – non-compliance within a Condition of Participation that does not trigger the entire COP to be out of compliance.
Your report may contain many more findings than you were expecting. CMS often assigns multiple “tags” to a situation found to be out of compliance. So, for example, a finding might identify that administration of medication in radiology was found to be out of compliance. That could be cited in Pharmaceutical Services, Radiologic Services and Governing Body. It is not unusual for 2567 reports to be 10, 15 or 20 pages long.
Each deficiency must be separately addressed and each plan of correction must include the following elements:
- The plan for correcting the issue found to be out of compliance which addresses the related processes
- How the plan will be implemented in the organization
- The date each deficiency will be corrected
- A description of how the corrective action will be monitored through the quality assurance/performance improvement (QAPI) structure of the organization
- The title of the individual responsible for implementing the corrective action
Some helpful hints:
- Plans of correction should be succinct yet specific to the COP tag at which they were identified.
- Corrective actions should, whenever possible, be implemented prior to submission of the completed 2567 to CMS. At most, you would expect to see a 30 day timeline with the exception of actions requiring significant capital resources.
- Engage leadership and medical staff in development and implementation of action plans to assure appropriate compliance is achieved in the identified timeframe.
- Assure measures of success are included on QAPI agendas and in minutes until compliance is achieved.
We hope you have benefitted from this series on CMS surveys and response activities. Click here to download a PDF containing all four articles in the series. Should you have questions or like to discuss any of these articles with one of our experienced consultants, please contact us at info@courtemanche-assocs.com.