March 2013

On Guard at All Times
By Selena Chavis
For The Record
Vol. 25 No. 5 P. 22

If CMS surveyors knocked on your door tomorrow, would you be prepared?

Surveys, audits, reviews: There are so many initiatives that could bring the Centers for Medicare & Medicaid Services (CMS) to a healthcare organization’s doors these days that many hospital executives are left feeling like they must constantly look over their shoulders. While there is ample reason for hospital personnel to feel some angst in anticipation of a potential visit, industry professionals suggest that much of the worry could be negated if an organization simply takes the necessary measures to deliver the best patient care.

“It isn’t about survey readiness; it’s about doing the right thing for the patient every time,” says Kimberly Baer, CJCP, an accreditation compliance coordinator with Illinois-based Herrin Hospital, a 114-bed acute inpatient and outpatient hospital. “The federal government has a small pot of gold, and they don’t have enough to give everyone, so they are going to give it to the best performers.”

While much of the industry buzz in recent years has been focused on revenue audit initiatives, the ongoing potential for a regular CMS survey must be taken just as seriously: Hospitals must be prepared from top to bottom. Baer, who points out that these surveys are more in line with what an organization can expect from a Joint Commission visit, says the scope of the effort covers “an entire hospital, from helipad to boiler room.” In contrast, a revenue audit is more patient-record focused to determine whether documentation matches medical necessity for billing.

There are three general categories of CMS surveys: certification/recertification, complaint/allegation, and validation.

Certification surveys occur during the initial comprehensive review when an organization submits an application to become a CMS provider. Likewise, recertification occurs on a cyclical basis to ensure a hospital or healthcare organization is maintaining standards that comply with CMS requirements.

Complaint or allegation surveys occur in conjunction with a credible complaint. Since a hospital may not be aware a complaint has been made, these surveys can take place unexpectedly. While the survey’s scope typically is limited to the complaint’s nature, the CMS can expand its review at any time to be more comprehensive.

Typically conducted by state agencies in cooperation with the CMS, validation surveys are completed by random sample to validate the accreditation process. According to Baer, a hospital that has been accredited by The Joint Commission and deemed Medicare compliant is subject to a validation survey in order for the CMS to ensure it truly meets the stringent federal requirements.

Around 2010, there appeared to be an uptake in validation surveys across the country, causing heads to turn in the industry, notes Bonnie Purdy, RHIA, vice president of HIM consulting and strategic sourcing services with Precyse, an HIM technology and consulting firm. In recent years, however, the number seems to have leveled out.

“We have not seen as many validation surveys with our clients,” she says, noting that most of what is occurring seems to be more focused on follow-ups to patient complaints. “They seem to be focusing more on bigger patient safety issues.”

Purdy points out that the reason for more focus on surveys related to patient complaints could be the result of the general public becoming more educated about their rights and where to go for resolution.

Industry experts agree that hospitals should not let their guard down. Any kind of CMS survey is serious, and all the necessary steps should be taken to ensure compliance at all times. Purdy emphasizes that this kind of readiness requires daily monitoring. “If they walked in tomorrow, are you ready for that kind of event?” she asks. “Those departments not monitoring on a daily basis, without the proper checks and balances in place, and without ongoing education, are the ones that won’t be ready when surveyors arrive.”

What to Expect
Expect the unexpected: That’s the advice offered by Angela Worden, managing director of FTI Consulting’s healthcare group. “Unfortunately, there is no consistency, and they can surprise you,” she explains. “What is done at one facility may not be done at another.”

While a CMS validation survey will encompass a similar scope of environmental, patient, and operational practices within a hospital, Baer says a Joint Commission survey has a much different feel. “Joint Commission is intense, but it doesn’t ‘hurt,’” she says, pointing out that in her experience, Joint Commission surveys are much more consultative in nature because the hospital is paying. “It gives staff a comfort level.”

In contrast, Baer says CMS surveyors have no incentive to take a customer-focused approach; they are there simply to get a job done.

Baer notes that Herrin Hospital’s experience with a CMS survey proved to be more involved and lengthy. Conducted by the Illinois Department of Public Health, the hospital was reviewed by four nurses for four days, with two additional surveyors covering life safety issues for three days. In comparison, The Joint Commission brought in two surveyors—a physician and a nurse—for three days, plus a life safety surveyor for one day.

The length of time can vary, Purdy says, adding that surveys are unannounced, and there is no specified duration for how long surveyors will be present. “That can be scary as well,” she says.

Worden notes that patient safety, security, and confidentiality are key focus areas. “Surveyors are on the lookout for HIPAA violations, obvious and not so obvious,” she says, adding that these violations continue to be an issue. “We want to make sure patient information does not end up in trash barrels and other unsecured areas. Are computer screens left open with [confidential] info available? Is there loose filing? Fax machine exposure?”

Other hot-button areas include patient safety issues such as falls, restraints, infection control, life safety, and environment of care. Surveyors specifically are looking for well-developed policies and procedures, and evidence of compliance with those procedures.

In all likelihood, requests will be made in relation to medical records representing certain diagnosis-related groups. The CMS on-site survey process typically follows tracer methodology, an evaluation strategy in which a patient record is requested and used as a road map to move through an organization’s processes. Surveyors use this methodology to assess and evaluate compliance with selected standards and the organization’s systems of providing care and services.

HIM plays a pivotal role. “Some facilities have experienced requests for a record where the query was asked to be produced and the facility couldn’t produce it,” Worden says. “That caused issues.”

In these cases, Baer notes that a one-hour time frame often is required to produce the record, which can be challenging for many organizations. Pointing to the hybrid record environment that exists in most healthcare organizations today, where both paper and electronic medical records exist, she says HIM departments “need to know where to find what they [CMS surveyors] want.”

For example, Baer says a record from several years ago may be requested. Is it stored on or off site? Has the record been scanned into the EMR?

Purdy points out that a single patient record may not even be located in the same place. “The entire record may not be in the EMR yet, and staff may have difficulty finding the full record,” she notes. “Also, surveyors may request that electronic records are printed—a time-consuming request for HIM. The challenge is being able to allocate the time needed to produce what has been requested.”

In 2012, the CMS announced its Patient Safety Initiative to test three revised surveyor worksheets for assessing compliance with three hospital Conditions of Participation: quality assessment and performance improvement, infection control, and discharge planning. According to Baer, the effort is intended to reduce the potential for hospital-acquired conditions, including healthcare-associated infections and preventable readmissions.

The CMS is continuing to review and revise the worksheets while the program is being piloted in fiscal year 2013. If a hospital is part of the pilot, “no citations will be issued at either the standard or condition level on the Form CMS 2567, Statement of Deficiencies and Plan of Correction, unless an immediate jeopardy situation is identified,” according to the CMS.

When deficiencies are found, healthcare organizations have 10 days to respond to the CMS. “That’s not much time,” Baer notes, adding that once a corrective plan of action has been submitted, there typically will be some back and forth before the CMS puts its own signature on the final draft.

Pointing to the importance of immediately following through with any corrective plan, Baer says the surveyors often come back to “make sure you did what you said you were going to do.”

Achieving a State of Readiness
Industry experts agree that the best defense to a CMS survey is to go on the offensive. Instead of scrambling when the CMS knocks on the door, Purdy suggests proactively implementing strategies that are consistent with comprehensive and effective compliance programs. Elements should include written policies and procedures, standards of conduct for ongoing training and education, and solid internal controls and corrective actions.

Critical to being aware of potential issues is daily monitoring, Baer says, pointing to the importance of manager rounding and concurrent chart review, where potential problems can be identified and corrected in real time.

Following the CMS tracer methodology, Baer regularly traces random charts as they wind their way through various departments. Much like CMS surveyors who will observe and talk with staff throughout the process, Baer engages with any department that “touches a patient. It’s important to have staff explain why they do certain things.” She adds that consistency of process between departments is critical. “If I ask two different departments the same question, I should get the same answer.”

Regular staff training regarding identified issues also should be an integral component of compliance strategies. Baer points to the following best practice areas to meet survey compliance measures:

• regular monitoring and education to keep leaders and frontline staff ready;

• daily conversations with staff so they are comfortable talking about the whys of policies and procedures; and

• a focus on the standardization of workflow and consistency of processes across the entire organization.

“As a survey coordinator, I need to know what the issues are before the survey team comes,” Baer says. “That means I need to establish good rapport with more than 800 employees.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.