In the previous posts we started discussing the various tasks in a hospital survey. We are now at Task 4 of the tasks that a nursing home and hospital surveyor must do during a hospital survey.

In Task 4 the hospital survey team takes all their findings and integrates them. They review and analyze all the information collected from observations, interviews, and record reviews, and they determine whether or not the hospital meets the Conditions of Participation This initial decision-making and analysis of the findings assist the hospital surveyor team in preparing an exit conference report. The hospital surveyors share their findings, evaluate the evidence, and make decisions as a team regarding the hospitals compliance with each requirement. If the hospital survey team determines it needs additional information in order to determine if the hospital is in compliance with the regulations, the team coordinator decides the best way to conduct the additional review.

Task 5, the Exit Conference, is to inform the facility staff of the team’s preliminary findings. Most times these are friendly, non confrontational conferences, while other times there can be an air of hostility. It is CMS’s general policy to conduct an exit conference at the conclusion of each survey. However, there are some situations that justify refusal to continue or to conduct an exit conference. For example: the nursing home and hospital surveyors may refuse to conduct the conference if a facility lawyer tries to turn it into an evidentiary hearing. Also, if the facility creates an environment that is hostile, intimidating, or inconsistent with the informal and preliminary nature of an exit conference, the nursing home and hospital surveyors may refuse to conduct or continue the conference. If the facility wishes to audio tape the conference, it must provide two tapes and tape recorders, recording the meeting simultaneously. The surveyors then take one of the tapes at the conclusion of the conference. Video taping is also permitted, at the sole discretion of the nursing home and hospital surveyor(s) and if it is not disruptive to the conference, and a copy is provided at the conclusion of the conference. After the exit conference, all of the team members will leave the facility together immediately.

Task 6 covers the preparation of the Statement of deficiencies, receipt of the hospital’s plan of correction, and the timeline for any other type of action taken, such as decertification. This is something we can discuss much further in future posts.

Be informed and be safe!


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In the previous posts we started talking about how a nursing home and hospital surveyor conducts a hospital survey and the various steps, or tasks, involved. We are up to task 3.

Task 3, the Information Gathering and Investigation phase, focuses on actual and potential patient outcomes, as well as the processes the hospital is required to have in place. It is during this time that the Hospital Survey team assesses the care and services provided to the patients. The Hospital Surveyor will visit all the patient care settings, including inpatient units, outpatient clinics, anesthetizing locations, emergency departments, imaging, rehabilitation, remote locations, satellite locations, etc. The members of the team will observe the actual provision of care and services to patients in every area of the hospital and the effects of that care. The team constantly communicates with each other in order to determine if they have any critical issues. The survey team members can also decide to have a hospital staff member accompany them or to go about the facility without an escort. Personally, I usually find it prudent to have staff come with me for several reasons. They can answer my questions or find someone quickly who can, they can get me from one unit or area to another without me needing a map, and they are witnesses to issues I find as I go about the hospital. If I want to privately interview a staff, patient, or visitor, I ask the accompanying staff to leave.

As an aside right here, I find it quite annoying when there are 6 or 8 staff following my every move. Several questions come to my mind in those instances:

  1. Who is caring for the patients if there are 6 or 8 people following every surveyor
  2. What are they afraid I will find that they want 6 or 8 people following me around? One staff accompanying me is enough, and sometimes two is OK as one can go find an answer to a question while the other continues to go around with me.

I will say, it is interesting (and funny) to see staff  “scurry” when a hospital surveyor approaches. I remember on one survey how I was going around with 1 staff member and there was another who kept disappearing around the corner every time I turned around. I wonder if she thought I didn’t notice her disappearing every time I turned around.

The hospital staff often have many questions and will ask a hospital surveyor for his or her guidance on how to correct a problem. Because the team is a representative of a regulatory agency, it is not in the role of a team member to provide consultation. Some states, though, do allow some limited consultation with the facility. The problem is that the hospital or facility then says, “But the state said……”

The hospital surveyor will also do a comprehensive review of care and services received by each patient in the sample. A comprehensive review includes observations of care/services provided to the patient, patient and/or family interview(s), staff interview(s), and medical record review. Observations provide first-hand knowledge of hospital practice and provides valuable information about how the care delivery system works and how the hospital’s departments work together to provide care. Interviews provide a method to collect information, and to verify and validate information obtained through observations. Document review focuses on a facility’s compliance with the Conditions of Participation. Documents reviewed may be both written and electronic and include but are not limited to patient?s clinical records, personnel files, credential files, maintenance records, staffing documents, policy and procedure manuals, committee meeting minutes & records, and contracts.

In the next post we will continue with our discussion of the steps and processes that a nursing home and hospital surveyor follows when conducting a hospital survey.

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In the previous post we started discussing the process a nursing home and hospital surveyor goes through to conduct a hospital survey. We got through the first step (task 1).

After Task 1 is completed, the survey team goes to the hospital. This is part of Task 2, The Entrance Activities. During this task the hospital survey team explains the survey process to the hospital and obtains the information they need to conduct the survey. All of the nursing home and hospital surveyors who are on the team should enter the hospital together and present their identification. They announce to the Administrator, or whoever is in charge, that a survey is being conducted. Sometimes the team arrives and the administrator is not available. That is OK, the survey team will not delay the survey.


After the team enters, the team coordinator will conduct what is called an “entrance conference”. This is a short conference that explains the purpose and scope of the survey to the administrator of the hospital and to any staff that are present at the entrance conference. The team coordinator will clarify information with the hospital, discuss expectations for the survey, and get additional information the hospital surveyor team will need. There will also be arrangements made for the team to have a location where they can meet privately during the survey.

In a hospital survey there is no initial tour. This is different than the Nursing Home survey, which we will discuss in other posts.

After the entrance conference, the hospital surveyor team will meet in order to evaluate information gathered, and, if needed, modify any surveyor assignments, as necessary.


A survey requires the review of a certain number of patients and patient records. The hospital survey team will select the patient sample by reviewing the patient list provided by the hospital and selecting patients who represent a cross-section of the patient population and the services provided. The sample size at mid to large hospitals is at least 10 percent of the average daily census, but not fewer than 30 inpatient records. For small general hospitals with an average daily census of 20 patients or less, the sample selected by the survey team will not be fewer than 20 inpatient records. Within the sample, the hospital survey team will select at least one patient from each nursing unit (e.g., med/surg, ICU, OB, pediatrics, specialty units, etc). In addition to the inpatient sample, the nursing home and hospital surveyors will select a sample of outpatients in order to determine if the facility is in compliance with regulations in all their outpatient departments, services, and locations. The sample size may be expanded as needed to assess the hospital’s compliance with the CoP.

In order to protect the confidentiality of the patients selected, the survey team ensures each patient in the sample is given a unique identifier. Patient names and other personally identifiable information is not used when the team writes up the problems found in the survey.

We will continue this discussion in the next post.

Be Safe!


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In the previous post we started discussing aspects of the hospital survey and how the nursing home and hospital surveyor starts to prepare for the survey. We will continue with a discussion of the tasks (steps).

The hospital survey has 6 “tasks”. These are:

  • Task 1 Off-Site Survey Preparation
  • Task 2 Entrance Activities
  • Task 3 Information Gathering/ Investigation
  • Task 4 Preliminary Decision Making and Analysis of Findings
  • Task 5 Exit Conference
  • Task 6 Post-Survey Activities

A hospital survey has a “team coordinator” who leads the survey team. The team coordinator assures that all survey preparation and survey activities are completed within the appropriate time frames and that the survey is conducted following federal protocols.

The Hospital Survey team coordinator duties may vary slightly from state to state, but they usually include the following:

  • Scheduling dates and times of survey activities;
  • Acting as the spokesperson for the team;
  • Assigning tasks and duties to the hospital surveyors tasks
  • Ensuring the hospital survey team is completing the survey in a timely manner;
  • Encouraging on-going communication among team members;
  • Evaluating team progress and coordinating daily team meetings;
  • Coordinating any ongoing conferences with hospital leadership
  • Providing on-going feedback, as appropriate, to hospital leadership on the status of the survey;
  • Coordinating Task 2, Entrance Conference;
  • Facilitating Task 4, Preliminary Decision Making;
  • Coordinating Task 5, Exit Conference; and
  • Coordinating the preparation of the Form CMS-2567 (the Statement of deficiencies that the hospital will receive after completion of the survey).

The team will prepare for the survey off site so they are ready to begin the survey immediately upon entering the facility. This preparation is called Task 1 (Off-Site Survey Preparation). The hospital survey team will analyze information about the hospital so they can identify areas of potential concern to be investigated during the survey. The hospital survey team will also determine if there are potential concerns or any special features of the hospital require the addition of any specialty surveyors to the team. This information will also allow the team to determine how many people should go on the survey.

The information the survey team will look at includes the facility’s ownership, the type(s) of services offered, the number, type and location of any off-site locations, Previous Federal and state survey results, the number, frequency, and types of complaint investigations and the findings, waivers and variances, if they exist, and any additional information available about the facility (for instance: the hospital’s Web site, any media reports about the hospital, etc).

This is one place where your letters to the licensing agency can help. If you have problems or complaints about a hospital, you should be sure to write to the licensing agency over that hospital. These complaints appear in the hospital?s file and they can help the survey team prepare for a hospital survey.

We will continue with the rest of the tasks in the next few posts. Hopefully this explanation of what happens during a survey will help you understand the role of a nursing home and hospital surveyor.

Keep Safe!


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