How A Hospital Surveyor Conducts The Hospital Survey - Part 1
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:
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Task 1 Off-Site Survey Preparation
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Task 2 Entrance Activities
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Task 3 Information Gathering/ Investigation
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Task 4 Preliminary Decision Making and Analysis of Findings
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Task 5 Exit Conference
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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:
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Scheduling dates and times of survey activities;
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Acting as the spokesperson for the team;
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Assigning tasks and duties to the hospital surveyors tasks
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Ensuring the hospital survey team is completing the survey in a timely manner;
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Encouraging on-going communication among team members;
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Evaluating team progress and coordinating daily team meetings;
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Coordinating any ongoing conferences with hospital leadership
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Providing on-going feedback, as appropriate, to hospital leadership on the status of the survey;
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Coordinating Task 2, Entrance Conference;
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Facilitating Task 4, Preliminary Decision Making;
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Coordinating Task 5, Exit Conference; and
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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!
JL
Filed Under Hospitals, Regulations, Survey Task |
Tagged With Hospitals, SOM, State Operations Manual, Survey Instructions, Survey tasks, Surveyor
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