Foundation
Federal agency that includes Medicare and Medicaid; regulates quality of care and promotes beneficiary awareness of benefits.
What is Centers for Medicare & Medicaid Services?
For example, the Joint Commission surveys on behalf of CMS.
What is deemed status?
The symbol D - with a circle around it?
What symbol indicates "Required Written Documentation? (Does not apply to documentation in the medical record).
Promotion of safe, functional and supportive environment: Safety and Security, Hazardous Materials, Fire Safety, Medical Equipment, and Utilities
What is the Environment of Care?
Oversight of quality of care, treatment and services; competency of practitioners; leadership in performance improvement; rules and regulations.
What are elements of the Medical Staff chapter?
Regulatory requirements that must be met to receive Medicare and Medicaid patients.
What are CoPs - Conditions of Participation?
Standard, Rationale, and Element of Performance.
What are the components (or structure) of the Joint Commission chapters?
AFS
What is Accreditation with Follow Up survey (AFS)?
Maintaining egress.
Keeping fire extinguishers, medical gas panel free of obstruction.
Fire compartments; smoke barriers.
What are elements of the Life Safety Code?
Review of care from the point of admission through discharge, to verify that care was provided appropriately, safely and per policy. patient care units, ambulatory areas, diagnostic testing, pharmacy.
What is the Tracer Methodology?
Surveys: Initial, Recertification, Complaint (for cause), Revisit, and Validation.
What are types of CMS Surveys?
Expectations that must be met to demonstrate compliance.
What is Element of Performance?
SEA
What is Sentinel Event Alert?
One of the most effective ways to prevent the transmission of infection.
What is hand hygiene?
Telling the surveyor more than they ask; taking the surveyor to an area they did not ask to see; trying to keep the surveyor contained to one area.
What are some responses or behaviors employees should not do when with a surveyor!
Provider's non-compliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient.
What is Immediate Jeopardy (CMS)?
A plan to demonstrate correction of requirement for Improvement (RFI).
What is "Evidence of Standards Compliance"?
ILSM
What are Interim Life Safety Measures?
Safety and quality of care, treatment of services: Culture of quality and safety survey results, evaluation of contracted services, implementation of policies and procedures.
What are processes addressed in the Leadership standards?
Knowledge, technical skills and ability.
What are elements of Competency?
Complete CMS Form 2567
What is the form for Statement of Deficiencies and Plan of Corrections?
ICM
What is the acronym for Intracycle Monitoring Profile?
OPPE/FPPE
What are Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation?
Current order sets, storage according to manufacturer guidelines, security, therapeutic duplication.
What are elements of the Medication Management chapter?
Survey Analysis for Evaluating Risk.
What is the SAFER Matrix?