It’s Friday and your triennial accreditation survey just ended. Your Joint Commission surveyor has informed you that one or more deficiencies were scored under the Centers for Medicare and Medicaid Services (CMS) “Conditions of Participation,” which will lead to a “Condition-Level Finding” for your organization, meaning that you are a candidate for a “Medicare Deficiency Follow-Up Survey.”

That’s right — they’re coming back unannounced within 45 days to ensure your organization has met the identified Conditions of Participation.

Take a deep breath. You’ve got a few days before you can log in to view your final report on your Joint Commission intranet site. When the time arrives, you are laser-focused on identifying the severity of your findings but don’t know how to weed through the gobbledygook and get to the nuts and bolts of the report.

Don’t panic! There’s a sure-fire path for getting the information you need and getting across the compliance finish line quickly.  Stay focused and follow these steps.

8 Steps to A Successful Medicare Deficiency Follow-Up Survey

To begin, head straight for the chart, “What’s Next-Follow-up Activity,” on page 4 of the final report from TJC to identify the deficiency(s) and the timeframe(s) for completion. Focus squarely on the second column from the right titled “Included in the Medicare Deficiency Survey (within 45 Calendar Days).”

This is your window into what needs to happen now! Forty-five days comes quickly, so let’s get moving.

Step 1: Turn to “The Requirements for Improvements” page. Hone in on all observations related to Life Safety (LS) and Environment of Care (EC).

Note:  If an LS deficiency was corrected during the survey and acknowledged by the surveyor, the observation will end with the following: “The finding was observed during survey but was corrected prior to the surveyor’s departure.”

Step 2: Download the Excel worksheet from your intranet site and list the deficiencies that must be addressed/corrected within 30 – 45 days.

Step 3: Start with the deficiencies depicted within the “High Risk” category of TJC’s SAFER Matrix and work systematically down the matrix.

Step 4: Take a photo for evidence of standards compliance (ESC) as each deficiency is corrected.

Note: If a repair requires parts that are on backorder and will not arrive in 45 days, contact The Joint Commission’s Standards Interpretation Group engineering team for guidance, and be prepared to present your purchase order to the surveyor. If it appears you will not be able to correct the deficiency within 60 days, you will need to apply for a CMS wavier.

Step 6: Check your TJC Connect ™ secure intranet site daily for notification of surveyors’ arrival.

Step 7:  Plan for the surveyors’ arrival. Pair your best team of subject matter experts with the surveyor; if need be, have a back-up team. Don’t forget to plan your route. Practice, practice, practice. Be in control of the moment.

Step 8: Time to shine! Relax and be personable. Don’t be a robot, but don’t be overly chatty. Provide only the requested documentation and stick to the prescribed areas for survey.

Voila…you’ve arrived!

If you have followed these steps, your race is over. You’ve had a successful Medicare deficiency follow-up survey.

Remember the words of Colin Powell: “There are no secrets to success. It is the result of preparation, hard work and learning from failure.”

You’ve learned a lot through this experience—now, you must put a strategy in place to maintain the gains. 


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About Ken Blackwell, LCSC, CHSP

Ken Blackwell, LCSC, CHSP, is a Senior Consultant with Compass Clinical Consulting. A former Joint Commission surveyor, Ken has surveyed nearly 600 healthcare organizations, including military hospitals and Veterans Health Administration facilities. He has nearly 20 years of experience in the healthcare industry, with expertise in the accreditation and regulatory standards and a commitment to continuous quality improvement in the areas of life safety, fire safety, equipment management, emergency management, utilities management, and safety management. Read more about Ken.

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