We’ve noticed an increase in regulatory scrutiny – especially among psychiatric hospitals. Frequent Immediate Jeopardy findings from CMS through contracted surveyors as well as evaluators from state agencies have been occurring.
In the first article of this series, Are You Doing Enough to Ensure Compliance with CMS’ Conditions of Participation (CoPs?), we discussed early warning signs for Board Members that would indicate their organizations are not doing enough to ensure compliance with CMS’ Conditions of Participation. Because there are many requirements within the Conditions of Participation, [...]
This final installment in our series on “Accreditation Options” helps hospital executives determine which accreditation source is the best match for their organization. Previously in the series, we analyzed the three main sources for external accreditation with deeming status from the Centers for Medicare and Medicaid Services (CMS): The Joint Commission (TJC), Det Norske Veritas [...]
Can you afford not to? For hospitals, the consequences of noncompliance with the Conditions of Participation can be enormous, especially when surveyors determine that Immediate Jeopardy (IJ) exists. IJ has the potential to lead to termination by the Centers for Medicare and Medicaid Services (CMS), This is part one of a four-part educational series that will provide hospital leaders with information on how to detect early warning signs that indicate their organizations are not doing enough to ensure compliance with CMS’ Conditions of Participation.
Recently we were asked to help a hospital that thought its finding of IJ had been abated, only to find out that the State Department of Health was overruled by CMS.
Part I of our series on “Compliance Cues”— ways to present an organization as well-prepared to meet or exceed a surveyor’s expectations— focused on establishing an environment of compliance starting at the front door. Part II explained the critical role of front-line staff and managers in responding to survey protocol in the most effective manner. [...]
Part I of our “Compliance Cues’ series dealt with setting the tone for survey either by The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS). In this installment, we will focus on the critical role of clinical staff in helping to assure a successful survey process. Clinical staff – whether physicians, [...]
In this, our third in a series of articles reviewing some of the options for hospital accreditation by regulatory bodies with deemed status from the Centers for Medicare and Medicaid Services (CMS), we will discuss the Healthcare Facilities Accreditation Program (HFAP). HFAP is the accreditation process that has grown out of the former hospital approval [...]
For-cause, complaint and unannounced surveys performed by the Centers for Medicare & Medicaid Services (CMS), State Departments of Health and The Joint Commission (TJC) are now regular features of hospital life. In states with vigorous departments of health, or those where the state has recognized financial penalties from noncompliant institutions as a revenue source, surveys [...]