What are the 4 deemed-status agencies for hospitals? - ANS The Center for Improvement in Healthcare Quality, JCO, Det Norske Veritas, and Healthcare Facilities Accreditation Program
Is accreditation by a deemed-status agency required for Medicare certification? - ANS No
What o...
What are the 4 deemed-status agencies for hospitals? - ANS The Center for Improvement
in Healthcare Quality, JCO, Det Norske Veritas, and Healthcare Facilities Accreditation Program
Is accreditation by a deemed-status agency required for Medicare certification? - ANS No
What options do hospitals have for Medicare certification? - ANS Direct certification,
accreditation by a deemed-status provider, or no certification
What is the role of the state enforcement agency? - ANS Investigating complaints,
conducting full validation surveys, issuing reports/findings, and recommending potential
terminations of hospitals to CMS
CCN - ANS Medicare certification number
Will a hospital be surveyed by CMS on provided services not billed under its CCN? - ANS
No
PPS - ANS Medicate's Prospective Payment System
Survey team coordinator - ANS Schedules dates/times of survey activities, team
spokesperson, etc.
Are hospital surveys announced or unannounced? - ANS Unannounced
Will CMS take a tour of the hospital? - ANS No
How large should the sample of patient records be? - ANS At least 10% of the average
daily census, but not fewer than 30 inpatient records
Will contracted patient care activities/services be surveyed as a part of the hospital for
compliance with the conditions of participation? - ANS Yes
Condition level deficiency - ANS noncompliance with standards or critical health or safety
breaches may result from single or multiple standards
, How many working days will the statement of deficiencies take to send out to the hospital? -
ANS 10 days
Form CMS-2567 - ANS the document disclosed to the public about the hospital's
deficiencies and what is being done to fix them
How many days is the hospital required to submit a written plan of correction to the survey
agency? - ANS 10 calendar days following receipt of the written statement deficiencies
What are some required characteristics of a plan of correction? - ANS Corrective action for
individuals affected by defective practices, including system changes, is required. Monitoring
position and frequency, completion dates, and approval from the State agency or CMS Regional
Office are crucial.
What consequences might occur if a hospital fails to submit a plan of correction? - ANS
possible termination
What are the 2 mechanisms CMS has that are available to hospitals that wish to challenge the
validity of a deficiency or the assignment of a condition-level deficiency? - ANS an informal
dispute resolution and requesting a formal judicial review with CMS at the federal level
Can separately certified hospitals be assessed together? - ANS No
What are the overarching responsibilities of the governing body? - ANS to provide the legal
authority for the establishment of a medical staff, assure that patients have access to
appropriate care, and to appoint a chief executive officer
According to CMS, how many CEO's can there be for an entire hospital? - ANS 1
Governing body - ANS a person or group of individuals who are legally responsible for the
conduct of the hospital
The governing body must take actions through the hospital's QAPI program to: - ANS
assess hospital staff services, identify quality issues, and monitor corrective activities for
sustainability
What must the governing body do if emergency services are NOT provided at the hospital? -
ANS assure that the medical staff has written policies and procedures for appraisal of
emergencies, initial treatment, and referral when appropriate
What are the important necessities when conducting appraisals of persons with emergencies? -
ANS a qualified RN is immediately available, recognizing when a person requires a
referral/transfer, and assuring appropriate handling of the transfer
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