Certification Process - ANS Hospitals have some options when it comes to Medicare certification:
• A hospital can be directly certified by Medicare
• A hospital can be accredited by a deemed-status provider
• A hospital can forgo Medicare certification entirely
Certification ...
Certification Process - ANS Hospitals have some options when it comes to Medicare
certification:
• A hospital can be directly certified by Medicare
• A hospital can be accredited by a deemed-status provider
• A hospital can forgo Medicare certification entirely
Certification Process - ANS ROLE OF THE STATE ENFORCEMENT AGENCY
With over 4000 hospitals across the United States, CMS does not have the manpower to
conduct on-site surveys. Therefore, CMS has ceded survey activities to each State. The State
Enforcement Agency (SA) is usually the Department of Health or similar body. The SA is
responsible for:
• Investigating complaints about hospitals and alleged violations of patient rights or other CoP'
• Conducting full validation surveys of a hospital's compliance to the CoP'.
• Issuing reports of findings and monitoring corrective action plans
• Recommending to CMS potential termination of a hospital's ability to participate in Medicare
payment programs
Certification Process - ANS MEDICARE CERTIFICATION NUMBER
Each hospital is assigned a unique certification number called a CCN. This number is used by
the hospital for any service under which Medicare is billed. CMS will assess a hospital's
compliance with the CoP for all services, areas and locations in which the hospital receives
reimbursement for patient care services billed under its CCN.
Certification Process - ANS COMPOSITION OF THE SURVEY TEAM
The State Enforcement Agency decides the composition and size of a survey team. In general,
a survey team for a full survey of a mid-size hospital would include two-four surveyors who will
be at the facility for 3 or more days. Each hospital survey team will include at least one RN with
hospital survey experience, as well as other surveyors who have the expertise needed to
determine whether the facility is in compliance. Survey team size and composition are normally
based on the following factors:
• Size of the facility to be surveyed, based on average daily census;
• Complexity of services offered, including outpatient services;
• Type of survey to be conducted;
,• Whether the facility has special care units or off-site clinics or locations;
• Whether the facility has a historical pattern of serious deficiencies or complaints; and
• Whether new surveyors are to accompany a team as part of their training
Certification Process - ANS All hospital surveys are unannounced. Hospitals are not
provided with advance notice of the survey.
Certification Process - ANS SURVEY ACTIVITIES
Arrival by the Survey Team
The entire survey team should enter the hospital together. Upon arrival, surveyors should
present their identification. The team coordinator should announce to the Administrator, or
whoever is in charge, that a survey is being conducted. If the Administrator (or person in
charge) is not onsite or available (e.g., if the survey begins outside normal daytime
Monday-Friday working hours), they will ask that the Administrator be notified that a survey is
being conducted. The survey will not be delayed because the Administrator or other hospital
staff is/are not on site or available.
Certification Process - ANS Survey Schedule
Unlike the deemed-status agencies, CMS does not provide a template or likely survey schedule
to hospitals. The Team Coordinator works with the other surveyors to determine where and
when various activities will take place. There is no set agenda or schedule of activities. The
amount of time spent in an area and the specific activities that occur in an area are left to the
surveyor's discretion.
Certification Process - ANS The number of patient records reviewed is based on the
facility's average daily census. The sample should be at least 10 percent of the average daily
census, but not fewer than 30 inpatient records.
Certification Process - ANS The number of patient records reviewed is based on the
facility's average daily census. The sample should be at least 10 percent of the average daily
census, but not fewer than 30 inpatient records.
Certification Process - ANS On any Medicare hospital survey, contracted patient care
activities or patient services (such as dietary services, treatment services, diagnostic services,
etc.) located on hospital campuses or hospital provider based locations will be surveyed as part
of the hospital for compliance with the conditions of participation.
Certification Process - ANS A deficiency at the Condition level may be due to
noncompliance with requirements in a single standard or several standards within the condition
or with requirements of noncompliance with a single part (tag) representing a severe or critical
health or safety breach. Even a seemingly small breach in critical actions or at critical times can
kill or severely injure a patient, and represents a critical or severe health or safety threat.
Certification Process - ANS THE CMS PLAN OF CORRECTION
, Following the survey a statement of deficiencies (Form CMS-2567) will be mailed within 10
working days to the hospital. Form CMS-2567 is the document disclosed to the public about the
hospital's deficiencies and what is being done to remedy them.
Certification Process - ANS The hospital is required to submit a written plan of correction to
the survey agency within 10 calendar days following receipt of the written statement of
deficiencies. The plan of correction is submitted on the Form CMS-2567. The required
characteristics of a plan of correction include:
• Corrective action to be taken for each individual affected by the deficient practice, including
any system changes that must be made;
• The position of the person who will monitor the corrective action and the frequency of
monitoring;
• Dates each corrective action will be completed;
• The administrator or appropriate individual must sign and date the Form CMS-2567 before
returning it to the survey agency; and
• The submitted plan of correction must meet the approval of the State agency, or in some cases
the CMS Regional Office for it to be acceptable.
Condition of Participation: Governance - ANS If a hospital system has chosen to have one
body act as the governing body for multiple separately certified hospitals, this does not alter the
fact that each hospital must separately demonstrate compliance with the CoPs. Each separately
certified hospital must be separately and independently assessed for its compliance with the
CoPs, through either State Survey Agency or approved national accreditation program surveys.
There is no survey of a hospital "system," since the Medicare agreement and its terms are
specific to each certified hospital.
Condition of Participation: Governance - ANS The governing body must take actions
through the hospital's QAPI program to:
• Assess the services furnished directly by hospital staff and those services provided under
contract,
• Identify quality and performance problems, implement appropriate corrective or improvement
activities, and
• Ensure the monitoring and sustainability of those corrective or improvement activities.
The governing body must ensure that the services performed under a contract are provided in a
safe and effective manner.
Condition of Participation: Governance - ANS The hospital must maintain a list of all
contracted services, including the scope and nature of the services provided.
Condition of Participation: Governance - ANS PROVISION OF EMERGENCY SERVICES
If emergency services are not provided at the hospital, or, emergency services are not provided
at any off-campus location of the hospital, the governing body must assure that the medical staff
has written policies and procedures for appraisal of emergencies, initial treatment, and referral
when appropriate
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