The Centers for Medicare and Medicaid Services (CMS) has a new quality improvement tool to gain compliance from hospitals with repeat or multiple Immediate Jeopardy (IJ) findings on compliance or validation surveys: the Systems Improvement Agreement (SIA). The SIA allows hospitals to continue receiving CMS funding while a third-party monitors its policies, facilities, and patient care until the [...]
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.
Many hospitals have experienced a finding of Immediate Jeopardy (IJ), the Centers for Medicare and Medicaid (CMS) term that notifies an institution that a threat to the health and safety of a patient (or patients) has been found on survey. Most organizations can successfully address an IJ within the short prescribed timeframe—usually 23 days. But [...]
It seems that it is more common than ever to read a news item that mentions a hospital in trouble with the Centers for Medicare and Medicaid Services (CMS) for violating one or more Conditions of Participation (CoP). This is a very big deal, as many hospitals have seen critical Medicare reimbursement streams threatened, and [...]
Effective November 18, 2011, CMS released for immediate implementation a relaxation of the “30-minute” rule for medications. With this change, only time-sensitive medications will still be required to meet the 30-minute time standard. On September 10, 2010, the Institute for Safe Medication Practices (ISMP) published results of a survey of nurses in which they self-reported [...]
The Centers for Medicare and Medicaid Services (CMS) requires that all Medicare inpatients receive written information about their discharge rights. CMS has defined how this “Important Message from Medicare” (IM) is to be delivered by hospitals to Medicare beneficiaries: The IM is a standard notice that must delivered to all Medicare inpatients on admission and [...]
In the second article of this series, “Are You Doing Enough to Ensure Compliance with CMS’ Conditions of Participation (CoPs)?,” we discussed early warning signs for Medical Staff members that could indicate their organizations are not doing enough to ensure compliance with CMS’ CoPs, This article focuses on Board “symptoms” of regulatory vulnerability that can be observed in “at risk” organizations.
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, [...]
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.