How A Hospital Surveyor Conducts The Hospital Survey - Part 4
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!
JL
Filed Under Hospitals, Regulations, Survey Task |
Tagged With Hospitals, SOM, State Operations Manual, Survey Instructions, Survey tasks, Surveyor
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