What Generates A Survey?

"For cause" surveys are initiated at any time there is a specific cause for concern at an organization, such as a complaint. At times a press release, legal action or investigative news story is the cause of a survey. Often, a "for cause" survey begins as a survey focused on one or two Conditions and expands as other questions are asked and not answered favorably. Thus, a survey can begin focused on a single Condition and expand to include all conditions.

The second type of survey is a "random" survey. Organizations which do not have deemed status through the Joint Commission or American Osteopathic Association are required to undergo a full "random" survey on an annual basis. Other "random" surveys include validation surveys, where the purpose is to validate that the Joint Commission or American Osteopathic Association survey process is equivalent in outcome to a CMS survey. Validation surveys are used to confirm the effectiveness of organizations such as the Joint Commission in conducting a survey process which is essentially equivalent to that of CMS.

What Authority Do CMS Surveyors Have?

The authority of individuals surveying on behalf of CMS is vast. The rule of thumb is that CMS surveyors are allowed access to materials they request, or federal funding is in jeopardy.

Who Conducts The COP Surveys?

Surveyors have many backgrounds and disciplines. The majority are nurses familiar with quality assurance programs. Fire safety professionals are generally included in the team to evaluate the facility against the Life Safety Code. Generalist surveyors review non patient care/clinical requirements. Clinical dieticians, rehabilitation therapists, pharmacists and respiratory therapists typically are dispatched to review their areas of expertise; however, nurse surveyors or generalists often review these conditions.

How Is The Survey Process Different From The Joint Commission?

• Little or no advanced warning
• No pre-established schedule
• Significant private review without hospital personnel present
• Punitive approach
• No educational component
• More time-consuming, thorough review
• Focused on noncompliance
• Joint Commission findings considered dubious
• Optional exit conference

Survey Results

What Are The Risks Of Poor COP Survey Results?

Noncompliance with an entire Condition or Conditions is the first step on the path to decertification. Organizations can be placed on a fast track to decertification in just 23 days. On the date of decertification the organization no longer receives Medicare funding and may not admit or treat Medicare patients. Typically contracts with other payers also require Medicare certification as a condition of the contract. The result is the loss of most of the revenue for the organization.

Not all COP deficiencies result in potential decertification. Deficiencies which are judged to be minor, such as that of a single standard where the rest of the Condition is compliant, result in a written report, but do not place the organization on the path to decertification. The organization must respond in writing with a Plan of Correction for each and every standard deficiency cited. It is important to understand the implications of noncompliance with the COP's; this Manual is dedicated to avoid noncompliance situations.