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This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe.

Former surveyor reveals common problems AOs miss, but CMS finds

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May 30, 2020

CMS has for several years expressed concerns that accrediting organizations (AO) have not been doing a good enough job during surveys.

Much of that concern comes from validation surveys CMS state agencies conduct in the wake of The Joint Commission (TJC), DNV GL Healthcare, the Healthcare Facilities Accreditation Program (HFAP), and the Center for Improvement in Healthcare Quality (CIHQ). In many of those surveys, until recently conducted as much as 60 days after the AO, CMS surveyors are finding what they consider obvious problems missed by the initial AO surveyors. (CMS is now validating AO results in real time.)

Those disparities, calculated into disparity rates, have been reported annually by CMS to Congress along with a list of most frequently missed problems, the majority of which fall under fire safety and physical environment.

The problems have become such a concern that CMS is writing a proposed rule to crack down on the AOs. The proposal went to the Office of Management and Budget for review in late February. When that rule becomes final, it likely will mean your AO will become even tougher than it is now.

But what are your AO surveyors really missing during their visits to facilities across the nation?

Brad Keyes, CHSP, a former TJC surveyor and advisor to  HFAP and owner and principal consultant for Keyes Life Safety Compliance, has catalogued over the years several examples that you can use to prepare for your next survey.

Here are his observations. Note that all references are to the NFPA 101-2012 Life Safety Code® (LSC), unless otherwise stated.

What are your AO surveyors really missing during their visits to facilities across the nation?



This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe.

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