The SA is responsible for: - ANS 1. Investigating complaints
2. Conducting validation surveys
3. Issuing reports of findings and monitoring CAPs
4. Recommending to CMS termination of payment
Survey team size is based off of: - ANS 1. Average daily census
2. Complexity of serv...
The SA is responsible for: - ANS 1. Investigating complaints
2. Conducting validation surveys
3. Issuing reports of findings and monitoring CAPs
4. Recommending to CMS termination of payment
Survey team size is based off of: - ANS 1. Average daily census
2. Complexity of services offered
3. Type of survey
4. Special units and/or offsite locations
5. Historical pattern of deficiencies
6. Surveyors-in-training
Does CMS provide survey template or schedule? - ANS No. Deemed status agencies do
though.
# of medical records reviewed by CMS during survey - ANS No fewer than 30 unless it's a
smaller hospital in which case, it is 20.
Condition-Level Finding - ANS 1. Noncompliance with single standard or several standards
within the condition
2. Noncompliance with a single part representing a severe or critical health or safety breach
When is final report sent? - ANS Within 10 working days
When is hospital response (written plan of correction) to final report due? - ANS Within 10
calendar days
Plan of correction must include: - ANS 1. Corrective action for each deficiency
2. Position of person who will monitor CAP
3. Dates of anticipated completion
4. Administrator signature (for CMS surveys only)
5. Must meet approval of SA (for CMS surveys only)
, Can you have one governing body for multiple separately certified hospitals? - ANS Yes, as
long as it doesn't conflict with state law. Each hospital will continue to have its own survey
(demonstrate compliance independently of the others).
Responsibilities for Contracted Services (GB and Hospital) - ANS GB: 1) Assess services
furnished under contract, 2) ID quality & performance problems and respond, 3) monitor CAPs
Hospital: Maintain list of contracted services, including scope and nature of services provided
Emergency Medical Treatment & Labor Act (EMTALA) - ANS For facilities without
emergency services, the medical staff must develop policies & procedures for appraisal of
emergencies, initial treatment (stabilization), and referral. Facility maintains responsibility for the
patient until properly transferred. Hospital cannot rely on 9-1-1- to substitute emergency
response.
Requirements for Informing Patients of their Rights - ANS 1. Must be done in advance of
furnishing or discontinuing patient care whenever possible
2. Must be provided in a language or manner the patient (or representative) can understand
Important Message from Medicare Requirements (IM) - ANS (For Medicare Patients)
1. Must be signed and dated by patient.
2. Must be presented no more than 2 days prior to discharge.
3. If inpatient stay is short, initial presentation of IM is sufficient.
Patient Right to Make Informed Decision - ANS 1. Must be informed of health status
2. Must be involved in care planning/treatment
3. Must be able to request or refuse treatment (that is medically necessary)
Advance Directives Requirements - ANS 1. Hospital must provide written information at
time of admission of right to formulate advance directive (Outpatient: only required for ED,
same-day surgery, for obs status patients).
2. Patient decision must be documented in medical record.
3. Must not condition provision of care based on execution of AD.
4. Must inform patients that complaints can be submitted to SA.
5. Provide staff education on AD policies and procedures.
6. Provide community education.
Requirements for Patient Visitation - ANS 1. Must allow visitors.
2. Restrictions/limitations must be clinically necessary or reasonable. Reason must be included
in the policy.
Requirements for Notifying Patient Representative of Admission - ANS 1. Must ask patient
if they want anyone notified.
2. Must notify representative promptly.
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