When survey time is drawing close, staff always wonder, “What are the surveyors going to be looking for in my area?” or “How should I be doing this (insert task) so we’re survey ready?”. Sometimes it seems that surveyors show up to your facility with a laundry list of things they will focus on but the criteria they will use to review your delivery of safe care (and how they will review) are already out there and ready for you to learn.
If your facility uses an Accrediting Organization for regulatory survey compliance, you should find guidance in their survey guides and in their respective standards. However, these standards are based on the Centers for Medicare and Medicaid Services (CMS) regulations found in the State Operations Manual and the associated programs found in the Appendices. Contained in these Appendices are the survey protocols, regulations and interpretive guidelines for the Conditions of Participation (COPs). These COPs are the minimum health and safety standards that organizations must comply with in order to qualify for reimbursement under the Medicare program.
To understand how the CMS COPs should be met and the process that surveyors use to evaluate them can be found in the interpretive guidelines and survey procedures found after each regulation entry. The playbook for the survey is provided to you with the regulations. It’s like an open book test! Understand that some interpretive guidelines are short while others are quite extensive. However, questions regarding how a surveyor will review a regulation and what they may look at to evaluate compliance may be answered within the interpretive guidelines and survey procedures. Check out the various programs at https://www.cms.gov/medicare/health-safety-standards/conditions-coverage-participation
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
