Has your psychiatric hospital been put in Immediate Jeopardy by CMS? Or, had a CMS survey with Condition level findings? Either way, you need to prepare for your CMS resurvey. So, it’s time to shift into high gear.
In our last article Immediate Jeopardy and CMS Surveys: How to Respond, we covered Immediate Jeopardy and your response strategy. In this article, we address how to prepare for your CMS resurvey.
CMS Resurvey Preparation
The State Survey Agency may (or may not) notify you that they accept your POC. Regardless, your goal now is to prepare for resurvey. And demonstrate you’ve corrected all the deficiencies in your 2567 report.
If you’re on a 90 day Medicare termination track, a resurvey should occur within 45 calendar days of your survey. The focus of the resurvey is to determine if you’re now in compliance with the Conditions of Participation (CoPs) cited as deficient in your report.
Scope of CMS Resurvey
The scope of the resurvey is typically limited to the CoPs found deficient on the initial survey. However, be aware that surveyors can expand that scope. If, during the course of the resurvey, they find other CoPs deficient, they can cite those as well.
Evidence of POC Implementation
Your paramount goal on resurvey is to show you’ve fully implemented your POC and resolved all the deficiencies. So, you need to organize all the evidence that demonstrates your compliance. That typically includes documentation of policy changes, staff training, and audit results.
We recommend you utilize Evidence Binders to organize your documentation of POC implementation. Include the following for each citation in your 2567 report:
- The CMS CoP and Standard number
- Your POC for that citation
- Documentation showing evidence of implementation of the POC for that citation
Organize the Evidence Binders with tabs, dividers, and labels. The goal is to make it easy for the surveyors to review the material.
Frequently, the action items in your POC involve developing new policies. Or, revising existing policies. Include copies of those new/revised policies in your Evidence Binder. For revised policies, highlight the changes from the previous policy.
Similarly, if you made changes to forms – such as treatment plans or mental status exams – include those revised forms with the changes highlighted. (For tips on treatment planning and mental status exams, see our previous posts Treatment Planning in Behavioral Healthcare: Survey Challenges and Tips for Documenting the Mental Status Exam.
For staff training, include a description of the training and copies of relevant training materials. Examples: a Power Point presentation, outline of a training curriculum, staff competency tests, etc.
Be sure to include data on when staff completed the training. Understandably, the training may occur over a period of time.
Don’t include reams of raw data such as sign-in sheets. Instead, aggregate the data. (You can have the sign-in sheets available if requested.) Remember, all staff must complete the training by the date you indicated in your POC.
Keep in mind your POC included your monitoring procedures to monitor your corrective actions. That means you need to include results of the audits you’re doing to monitor compliance. And documentation of who reviewed the audit results. And any actions taken based on those results.
A word of cation here. Too many hospitals conduct audits of their POC action items on a monthly or quarterly basis in their standing committees. This is not frequent enough when you’re facing a CMS resurvey. You need to monitor compliance weekly – or possibly even daily – to know you’re achieving the desired results.
POC Implementation on the Units
On the typical CMS resurvey, surveyors first review the Evidence Binders. Then, they go out on the units to review implementation of the POC “in vivo.”
They review medical records, observe patient care, and evaluate active treatment. They also interview staff, managers, and hospital leaders.
Thus, it’s critical to conduct mock surveys on your units to prepare for your resurvey. The goal here is twofold. First, to evaluate whether the POC has been implemented as written. Second, to prepare staff for how to interact with surveyors. And how to show surveyors the corrective actions now in place on the units.
An external, objective set of eyes is extremely helpful when preparing for your CMS resurvey. Barrins & Associates’ CMS Mock Surveys include document review, patient tracers, staff interviews, and technical assistance on preparing for a successful CMS resurvey.
CMS Resurveys: Policy vs. Practice
Keep in mind that even the most well organized Evidence Binders will not make up for inadequate POC implementation on the units. Surveyors expect to see policy changes and staff training. More importantly, they expect to see – in real time out on the units – that you’ve corrected the deficient practices they cited.
For example, maybe they cited you for lack of active treatment. In response, you revised your policy on active treatment. And developed a new program schedule.
That’s all good material for the Evidence Binders. But if surveyors tour the units and see patients lying in bed and the group schedule not consistently implemented, you’ll be cited again for this deficiency. (For more info on active treatment, see our post Surveying Active Treatment in Psychiatric Hospitals.
Survey Management Strategies
It’s critical to actively managing your CMS resurvey while it’s unfolding. So, use the following survey management strategies to ensure a smooth, successful resurvey:
- Keep a list of people to notify about the start of the survey. Include an updated telephone list.
- Designate a room as the surveyors’ meeting room (separate from where other meetings are held) so that they can use this as a home base.
- For any leader/manager absent during the survey, make sure there’s a designated backup person who can speak for that function.
- Designate a Command Central staffed by your PI Manager. Gets reports from the units as they’re visited. Maintains a bird’s eye view of what’s occurring throughout the survey.
- Be ready to provide active census lists for all units each day of survey.
- Assign an escort to accompany each surveyor.
- Assign a scribe to accompany each surveyor. Record the numbers of all medical records reviewed. And all questions the surveyors ask.
- Remove all “Sign Here” or other reminder stickers from records.
- Report to the upcoming units what transpired on the unit just visited.
- Respond to surveyor requests as quickly as possible.
- Turn off cell phones during meetings with surveyors.
- Meet at the end of each day to debrief and strategize.
- Fix anything that can be fixed while the survey is still in progress.
CMS Resurvey: Possible Outcomes
Following your CMS resurvey, the State Survey Agency will issue another 2567 Report. Hopefully, it will remove all the Condition level deficiencies.
If there are Condition level deficiencies, you’ll need to submit another POC and prepare for another resurvey. If there are only Standard level deficiencies, you may only need to submit a POC but not undergo a resurvey. Your cover letter from the State Survey Agency will explain the next steps.
When it comes to CMS, your ultimate goal is ongoing compliance with all the CMS CoPs applicable to your hospital. That means studying the CoPs and understanding the expectations for compliance.
On a positive note, the experience of a CMS survey/resurvey provides insight to what you must do to achieve ongoing compliance. And build it into your daily operations.
To help you achieve that goal, Barrins & Associates provides CMS Compliance Training as well as consultation on Integrating CMS and TJC Requirements. All geared to the special needs of the behavioral healthcare industry.