How a Hospital Surveyor Prepares For A Hospital Survey
Before a surveyor and the survey team enter a hospital or nursing home they must prepare paperwork, review records, and get a general idea of what the facility is like. The State Operations Manual describes how the surveyors are to prepare for the surveys. Hospital Surveys and Nursing Home Surveys have different steps, called “Tasks”. Although the tasks are listed in numerical order it does not necessarily mean they are conducted entirely in that order. Many times multiple tasks are being done at one time.
We will first talk about how the Hospital Surveyor prepares for a Hospital Survey.
The goal of a hospital survey is to determine if the hospital is in compliance with the Conditions of Participation at 42 CFR Part 482. If you remember from a previous post titled, “Where Oh Where Does a Nursing Home and Hospital Surveyor Find the Regulations?” the State Operations Manual (called the SOM) guides surveyors in how to prepare for and conduct a survey. The SOM also contains the regulations and guidance in interpreting those regulations. Appendix A contains the process for the surveying of General Acute Care Hospitals.
Determination that the hospital is in compliance with the Conditions of Participations is done through observations, interviews, and document/record reviews. The survey process focuses on a hospital’s performance of patient-focused and organizational functions and processes. The survey is unannounced, meaning the hospital is not to have advanced notice of the survey. A hospital survey is generally conducted during normal daytime working hours Monday through Friday, but a hospital surveyor and the hospital survey team may conduct surveys and investigations at any time, including nights, weekends, and holidays. The size of the survey team is dependent on a variety of factors such as size, complexity of the services provided by the hospital, the presence of special care units or “off-site” units such as clinics, and the hospital’s previous surveys and complaints. Usually for a full survey of a mid-size hospital the survey team includes 2-4 surveyors who will plan to be at the facility for three or more days. Every hospital survey team will include at least one RN with hospital survey experience, as well as other surveyors who have the expertise and training needed to determine whether the facility is in compliance.
Hospitals who want to receive Medicare and Medical payments MUST meet the conditions of participation. Should a hospital refuse to allow immediate access upon reasonable request to either a State Agency or CMS surveyor, the Office of the Inspector General (OIG) may exclude the hospital from participation in all Federal healthcare programs in accordance with 42 CFR 1001.1301
The regulatory authority that allows surveyors to photocopy records and other information during the survey is found at 42 CFR 489.53(a)(13).
Filed Under Hospitals, Regulations, Survey Task |
Tagged With Hospitals, SOM, State Operations Manual, Survey Instructions, Survey tasks, Surveyor
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