Regaining CMS Certification

Regaining CMS Certification

Setting the Scene

In one mid-sized regional medical center in the Southeast, poor executive and Board oversight, declining financial performance, and damaged relations with nursing and medical staff diverted the organization’s attention away from vital compliance issues. Following a complaint survey by the Centers for Medicare and Medicaid Services (CMS), the medical center received a notice of Immediate Jeopardy. Failing to correct the cited deficiencies, the organization was terminated from Medicare. In addition to its regulatory troubles, the medical center faced further challenges when several of its key administrators stepped down.

Crafting a Solution

Compass Clinical Consulting was engaged to help this medical center regain its Medicare certification. A team of interims, including an interim CNO, CMO, Director of Quality, Director of Emergency Services, and Director of Human Resources, was deployed to fill leadership vacancies and provide stability. Interims and consultants served as coaches for the administration and staff of the medical center, who learned to internalize the medical center’s problems and replace a defensive attitude with a positive one.

To begin addressing regulatory deficiencies, Compass consultants divided the CMS report into manageable sections. Summarizing the problems identified by CMS made them easier to understand and digest, and facilitated the process of determining what corrective action to take. Teams were then established to address each section of the report, and action plans were developed to correct each of the identified areas of non-compliance.

Seeing the Results

With the help of consultants, the medical center’s administration was able to repair relations between the medical center’s leaders and medical and nursing staff. Compass’ thorough, outside assessment helped the medical center’s staff and administrators in the development of new policies and procedures and their implementation in preparation for a full CMS survey. When CMS returned, the medical center passed the survey with flying colors and regained Medicare certification in a mere 110 days.

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