In October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI). They will be used by the state surveyors to assess compliance with the Conditions of Participation (CoPs) associated with those areas. CMS began piloting these worksheets in 2011 as part of its Patient Safety Initiative. The focus of the Patient Safety Initiative is to reduce hospital acquired infections and preventable readmissions. (One out of every five Medicare patients is readmitted within 30 days.)

CMS’ directive to the State Survey Agency Directors stated that the finalized worksheets are to be used for all SA hospital survey activity whenever assessment of compliance with any of the three associated CoPs occurs. This includes all complaint surveys involving assessment of compliance with one or more of these CoPs and full surveys including validation surveys, recertification surveys, and full surveys that the Regional Office requires after a complaint survey with condition-level noncompliance. The worksheets may be used individually or in combination based on specifics of the particular survey.

During the pilot phase, hospitals were not cited for noncompliance identified via the worksheets. Now that the worksheets have been finalized and officially made a part of the survey process, non-compliance will be cited on the Form CMS-2567 which is the survey report form.

So, what’s the impact for psychiatric hospitals? First, be aware that if you get a complaint survey (the most likely type of SA survey), the surveyors will be using these worksheets. We know of two psychiatric hospitals who recently had this experience. As part of a complaint survey, the SA surveyors used the QAPI worksheet to assess the hospital’s PI program. There was a heavy focus on the performance indicators that the hospitals had selected and the data collection methods they were using.

Second, study the worksheets and conduct a self-assessment. The best way to do this is to organize project teams for each of the worksheets: Infection Control, Discharge Planning, and QAPI. Have the team members complete the worksheets for each area and report their findings to your Leadership Team. For any areas of noncompliance, there should be specific recommendations for addressing the issues identified. Then the Leadership Team should decide which are the top priorities and develop action plans for addressing those noncompliant areas.

The next question is whether the expectations in these worksheets will eventually find their way into the TJC standards or survey process. We will stay tuned to that and keep you posted as things unfold.

For detailed information and copies of the worksheets, see CMS’s announcement of the Public Release of Three Hospital Surveyor Worksheets (external link).