Update on CMS Activities
CMS Complaint Surveys
It appears CMS Complaint Surveys of psychiatric hospitals may be on the rise. In the past year, several clients have undergone Complaint Surveys for the first time. Frequently, they have been cited on the Complaint Surveys for issues that had not been cited on their last Joint Commission survey.
Now that TJC has deemed status for the Two Special Conditions of Participation for Psychiatric Hospitals, the only reason that CMS would survey a TJC accredited psychiatric hospital would be for a Validation Survey or a Complaint Survey (also known as an Allegation Survey). Complaint Surveys are conducted when CMS receives a complaint and determines that it raises a "credible allegation" of a Condition level deficiency. At the outset of the Complaint Survey, the State Agency (acting on behalf of CMS) typically limits the scope of the survey to the CoP(s) related to the complaint. However, the State Agency has the latitude to expand the survey's scope and review areas beyond those involved in the complaint. If the State Agency identifies a Condition level deficiency, CMS will authorize a full Medicare survey. If the State Agency determines that the hospital is still out of compliance with one or more CoPs, the hospital is placed on a 90 day termination track from the Medicare program.
Why the increase in Complaint Surveys? One contributing factor may be that patients and families are better informed about quality of care issues in general and also better equipped (via Internet access) to pursue their complaints. Sources of complaints are typically the patient, the patient's family, or staff within the organization.
Once a Complaint Survey (and potentially a full survey) have occurred, it's critical for the hospital to respond with a comprehensive Plan of Correction and an effective process for managing that Plan of Correction. We recently came across a helpful resource on the whole CMS survey process: CMS Hospital Surveys: The Legal Perspective. It provides background on the different types of CMS surveys and guidance on how to respond to survey findings.
Be sure to stay on top of the CMS CoPs and any updates and revisions to the State Operations Manual. Appendix A contains the A Tags which apply to all hospitals (including psychiatric hospitals). Appendix AA contains the B Tags which apply only to psychiatric hospitals.
CMS Surveyor Worksheets
If you're interested in knowing the areas that CMS will be scrutinizing over the next few years, check out the third draft of the Hospital Surveyor Worksheets . There is one for Quality Assessment/Performance Improvement, one for Infection Control and one for Discharge Planning. The worksheets have been piloted and, once finalized, will be used as part of CMS's survey process. CMS is focusing on these three CoPs as a means to reduce healthcare acquired conditions and hospital readmissions. Although most of the probes in the worksheets relate to care provided in acute hospital settings, many have applicability to the psychiatric hospital setting as well.