As we know, TJC has deeming authority from CMS for both acute care hospitals and psychiatric hospitals. As part of its oversight of TJC’s deemed status survey process, CMS conducts validation surveys to assess TJC’s performance in evaluating a hospital’s compliance with the CMS Conditions of Participation (COPs.)  These validation surveys are conducted within 60 days after a hospital’s triennial TJC survey. The annual sample size for these validations surveys ranges from 2% to 5% of deemed hospitals. The surveys are conducted by the State Survey Agency on behalf of CMS. For psychiatric hospitals, they also typically include federal surveyors (a psychiatrist and a nurse) who survey the Special Medical Record Requirements for Psychiatric Hospitals (B Tags.) If a Condition level finding is cited on a validation survey, CMS removes the hospital’s deemed status and places it under the jurisdiction of the State Survey Agency until the hospital comes into substantial compliance. The hospital is notified of this via a letter from the CMS Regional Office and there is typically a 90-day timeframe for termination of Medicare participation.

Several of our clients have undergone validation surveys this year following their triennial TJC surveys and we know that funding has increased for both validation and complaint surveys. For some clients, it was a smooth process with no Condition level findings. For others, there were Condition level findings which then triggered the 90-day Medicare termination process. In some cases, the findings were different from the TJC survey findings. In other cases, the findings were similar to TJC’s but the hospitals had not sufficiently implemented their corrective actions to show full compliance and thus were cited on these issues again. In addition, we continue to see the same variability as always among the different State Survey Agencies in terms of what they cite and what they don’t cite. And, unfortunately, it’s often the case that these state surveyors are not behavioral health professionals.

One of the challenges with the validation survey process is that the report is often not received until several weeks after the survey ends. Clients frequently report that the CMS surveyors did not cite specific standards or findings in the exit conference. Rather, they indicated that detailed information would be in the written report. All too often, when the report arrives, the hospital is surprised at the extent and degree of the findings and begins the mad rush to develop a plan of correction that is due in 10 days. (That’s frequently when we get the call for assistance and begin to work with the hospital on their plan of correction.)

Given these circumstances, we strongly urge any hospital that has had a validation survey to get to work right away when the survey ends and begin to address any issues that came up during that survey. Don’t wait for the report and hope that the findings will be minimal. Even though you don’t have the official report, there should be plenty of information you gathered during the survey to tell you what the surveyors identified as weak areas. For example, in the records they reviewed, what did they look at — typically assessments, treatment plans, discharge summaries — and what were their comments? They usually speak to staff and managers while doing record reviews so what did they ask them about? Also, the surveyors typically interview managers and ask them to corroborate their findings. For example, they will meet with the Director of Social Services and discuss the psychosocial assessments they’ve reviewed and ask if she agrees that the assessments did not identify high-risk psychosocial issues requiring early treatment planning and intervention. If this scenario occurred during your survey, you can bet it will be in the report so you might as well go ahead and get working on it.

Once the final report (CMS 2567) is received, your initial plan of correction (developed right after the surveyors exited) will need to be revisited and reorganized so that it specifically addresses the deficiencies listed in the 2567 report. Each of the tags (and every finding within each tag) will need to be addressed separately to describe the corrective actions taken and how compliance will be monitored. We have found it most effective to organize the response for each tag as follows:

• Corrective Actions Taken
  • Immediate actions taken during the survey
  • Actions taken post-survey and prior to submission of the POC
    • Policies/procedures
    • Staff education
  • Monitoring
    • How the corrective actions will be monitored to measure success
  • Responsible Person
    • A single leader responsible for achieving and maintaining compliance

Developing a robust plan of correction for your 2567 report is a labor-intensive effort that requires teamwork, precision, and a leader with strong organizational and writing skills. When working with clients on this endeavor, we often use the guide developed by the American Health Lawyers Association: CMS Hospital Surveys: The Legal Perspective and have found it to be a very valuable resource. Be sure to check it out if you find yourself facing a Validation Survey.

If you need assistance maintaining compliance with CMS, learn more about our CMS Compliance support services.