ORM February 2023 - 29

REGULATIONS
BY JUDITH MATHIAS
Strategies for preparing and surviving a CMS survey
T
he Centers for Medicare and Medicaid
Services (CMS) develops
conditions of participation (CoPs)
and Conditions for Coverage (CfCs) that
healthcare organizations must meet in
order to participate in Medicare and
Medicaid programs.
Payers, including government payers,
require facility certification or accreditation
for reimbursement.
" Reimbursement is
the critical piece, " says
Becky Ziegler-Otis, MHA,
CASC, accreditation specialist
for Wausau Surgery
Center, Wausau,
Wisconsin, and an independent
ambulatory
surgery center
(ASC)
Becky ZieglerOtis,
MHA,
CASC
consultant, speaking at
the 2022 OR Manager Business Conference.
" If
you want to be reimbursed for the
surgical procedures you perform, you
are going to have to go through CMS
certification or have deemed status
through an accrediting organization, "
she says.
Deemed status
Deemed status means a facility has
chosen to go through an accrediting
organization, such as The Joint Commission,
Accreditation Association for
Ambulatory Health Care, Accreditation
Commission for Health Care, or Quad A,
rather than certification from CMS.
Accreditation is not a requirement in
all states, however, and organizations
seeking CMS approval may choose to
be surveyed by state surveyors on behalf
of CMS.
Either way, CMS ensures that the
standards of the accrediting organization
meet or exceed the Medicare standards
set forth in the CoPs and CfCs.
Types of surveys
* Validation surveys. These validate
results of a deemed status survey.
An accredited facility may also have
www.ormanager.com
Strategies for preparedness
There are four strategies for survey preparedness
(sidebar, Strategies for Preparedness):
*
Standards review
* Previous survey deficiencies
* Mock surveys, audits
* Survey readiness binder.
Standards review. " I have found that
the standards review process is the
most important for keeping prepared, "
says Ziegler-Otis. " Some may see this
as boring, but it isn't. It's insightful, and
it can be fun, " she says.
Ziegler-Otis notes that when she was
an administrator, she would scan the
most current version of a standard and
list what needed to be done to meet it.
Then she would engage the appropriate
staff, such as nurse leaders, quality
manager, risk manager, infection preto
go through a validation survey,
which happens within 6 weeks of an
accreditation survey. CMS performs
an onsite survey to confirm that the
accrediting agency did a thorough
job.
* Complaint surveys. These involve
a visit in response to an allegation
or deficiency received by CMS or an
accrediting agency. Typically, complaint
surveys just focus on a problem
and the issue behind it, for example,
keeping patients longer than
23 hours after surgery in an ASC. If
surveyors find something egregious,
they can expand the scope of the
survey.
* Initial surveys. The first time a new
center, just opening, seeks Medicare
or Medicaid status, it has to
undergo a full CMS survey.
* Recertification surveys. These are
full CMS surveys, every 3 years, performed
to ensure ongoing compliance.
*
Revisit surveys. These are visits to
verify that corrective actions were
followed through for identified deficiencies.
Strategies
for preparedness
Source: Becky Ziegler-Otis, MHA, CASC.
Used with permission.
ventionist, and facilities manager and
inform and collaborate with them on
what they had to do to have a successful
survey. The number of individuals
involved in this process depends on the
size of the facility-it could be 10, or it
could be two.
" Once you have your stakeholders
engaged, you set a date and time each
week or every other week to meet as a
group, and stick to it, " says Ziegler-Otis.
" You need to take your time and help
them understand what they are reading.
You can divide it up and go through a
certain number of standards each meeting.
This is important information, and
you shouldn't rush through it. "
Previous survey deficiencies. " If you
were surveyed before, you will have deficiencies,
and it would behoove you
to look at them before the surveyors
arrive, " says Ziegler-Otis. " Pull out your
previous surveys and take a look at
what they cited you for, your plan of correction
that you put into place, and your
monitoring activity of that plan. "
Ziegler-Otis recommends giving the
documentation of that monitoring activity
to the proper leader for an audit or
take it to a staff meeting and explain it
to everyone.
Continued on page 30
OR Manager | February 2023 29
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