How to Prepare for a CMS CoPs Survey — Strategies for Success

Several years ago, I received a call from a hospital's front desk informing me that there was a large number of men and women in suits with roll-on bags asking for me by name. The receptionist said, "Looks like they plan to be here for a while." I quickly ran to the front lobby and mentally stopped counting when I reached the count of 10 people, discerning that the state department of public health had arrived to conduct a validation survey. For hospitals that are facing a survey from their state department of health, the following information may be helpful in understanding the reasons behind the survey and how to best respond.

Catalysts for a CMS survey

State agencies conduct surveys for the CMS for a variety of reasons:

1. Certification/recertification surveys for initial license, validation survey or following an immediate jeopardy citation;
2. Complaint/allegation investigation; or,
3. Self-reported event investigations.

The CMS survey team

The size of the survey team varies according to the size of the facility, its average daily census, the complexity of services it provides — including off-site services — the organization's past history of deficiencies/complaints and the type of survey to be conducted. For example, two to four nurse surveyors may conduct a certification/recertification/validation survey for a mid-sized hospital, whereas a large facility may have eight or more surveyors onsite, along with several fire marshals, for an entire week. To investigate a complaint, the state agency may send one or two nurse surveyors for one to two days. Often, one or more trainees may accompany the survey team.

Warning signs of a CMS survey

Surveys are unannounced; however, sometimes there are signals that a survey may be imminent. For example, a patient, family member, visitor, physician or staff member may express their dissatisfaction with the care a patient received to staff members or may threaten to "file a complaint." Hospitals that act on this information and develop a plan of correction may find that they do not receive a "Statement of Deficiencies" CMS-2567 form following an unannounced complaint/allegation investigation by the state agency surveyors. CMS has instructed state agencies not to cite hospitals for noncompliance with a requirement in the CMS CoPs, if prior to the survey, the hospital recognized it was out of compliance, instituted a credible plan of correction — one that is comprehensive, prevents the deficiency from reoccurring, has been subject to Quality Assurance Performance Improvement review and is sustainable (unless an immediate jeopardy situation exists). Often, the organization may be unaware of a person’s intent to "file a complaint.  That’s where an aggregation and analysis of the organization’s past complaints/grievances can be used to determine the degree of extent — how far the noncompliance permeates into the hospital. Using a QAPI approach, the organization could then begin making self-corrections.

Statement of Deficiencies

The Statement of Deficiencies is cited at the standard level and condition level. The most serious citation, immediate jeopardy, indicates "a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death."

Immediate jeopardy

Immediate jeopardy may be triggered by failure to:

• Protect from abuse
• Prevent neglect
• Protect from psychological harm
• Protect from undue adverse medication consequences and/or failure to provide medications as ordered
• Follow nationally accepted standards of practice for infection prevention
• Correctly identify patients
• Safely administer blood or blood products
• Provide safety from fire, smoke and environmental hazards
• Comply with EMTALA requirements (CMS State Operations Manual, Appendix Q - Immediate Jeopardy, 2004)

New resources for compliance self-assessments

Over the past year and a half, state agencies have been conducting a pilot to test three worksheets on discharge planning, QAPI and infection control. For fiscal year 2013, CMS has instructed the state agencies to conduct pilots in one to nine hospitals per state, per year. The worksheets may be utilized while the surveyors are on-site conducting a validation or complaint survey, or hospitals may be selected at random. During the pilot, hospitals will not receive a citation for a deficiency, unless an immediate jeopardy situation exists. These worksheets are excellent resources for hospitals to use to conduct their own self-assessment of compliance.  

Now that CMS has started posting the statements of deficiencies listed on the Form 2567 from recent surveys on the Internet, hospitals may want to review the information to determine the type of citations similar organizations in their state received. For example, in one state, the most frequently cited deficiency may relate to restraints. By reviewing the details of the deficiencies listed on the CMS website, the organization may find that other hospitals were cited for restraining patients without orders, or not performing monitoring as ordered. Knowing the specifics of the deficiencies will enable the hospital to scrutinize its policies, modify their documentation requirements, educate their staff, and conduct self-audits, in advance and thus possibly prevent their hospital from receiving a deficiency.

Mock surveys — A tried and true strategy

Many organizations conduct mock surveys to prepare for The Joint Commission accreditation surveys. However, survey preparation for a CMS certification/validation survey is quite different. While the survey teams may be similar, the survey is conducted from a different perspective, with the CMS survey focusing more on chart audits and document reviews and TJC surveys utilizing the tracer methodology. One new twist to the CMS survey process is that tracers are being introduced into the worksheets described earlier. Using the same methodology as an actual survey, hospitals can gain comprehensive knowledge of their strengths, limitations and potential deviations from compliance with the CMS Conditions of Participation when they conduct mock surveys.

Preparing for CMS survey success

If your organization has not experienced a validation survey, received condition-level citations or been near the brink of death following an immediate jeopardy citation, then you are very fortunate. The following strategies are recommended to help hospitals successfully prepare for a CMS survey whether it’s for validation, complaint or a self-reported event:

1. Use your data wisely. Take the data you've collected from incidents, complaints, infection surveillance, satisfaction surveys,  performance measures, self-assessment worksheets and mock surveys, and analyze them for patterns and trends. But analysis isn’t the endpoint — take action based on your data to improve performance and consistency.
2. Learn from your mistakes and successes. Make sure information flows up and down the organization chart. Report QAPI information to the governing body as well as to the staff. Rather than displaying charts showing statistics, consider using infographics (pictures) or actual patient stories about events and/or the number of lives saved at your healthcare organization. The most important part is to discuss quality and safety, not just post it. Help all staff members understand their role in providing safe, quality patient care.
3. Don't accept mediocrity when it comes to patient care. While operational perfection is difficult to achieve, you must constantly strive toward perfection. Tolerance of error breeds more errors. Hold all staff members accountable for their actions/interventions.
4. Remember, practice makes perfect. Use all of the tools at your disposal to help you prepare not just for a successful survey, but also for the best patient experience at your hospital.

Victoria May Fennel, MSN, RN-BC, CPHQ, is the director of accreditation and clinical compliance for Compass Clinical Consulting.