Regulatory definitions
Term used by JHH to always be survey prepared. JHH uses the find-it-fix-it tool
What is Continuous Survey Readiness
The objective evaluation process that can help health care organizations measure, assess, and improve performance in order to provide safe, high-quality care for their patients
What is the Joint Commission accreditation?
This survey is required for deemed status or CMS recognition purposes.
What is an unannounced survey?
Functional participation as scribe, escort, subject matter expert (SME).
What are QI-PS staff survey activities?
Regulatory bodies may impose hefty fines on healthcare organizations that fail to meet compliance standards
What are financial penalties?
Term that refers to a designation granted by CMS to healthcare organizations that meet or exceed Medicare’s requirements through accreditation by a recognized accrediting body, such as TJC
What is CMS deemed status?
This survey plays a pivotal role in maintaining the integrity of accreditation organizations (AOs) and ensuring compliance with federal standards. The purpose is to assess the AO’s ability to ensure compliance with Medicare conditions
What is a CMS validation survey?
Timeline organizations can expect an unannounced survey by an authorized CMS accreditation organization to determine deemed status
What is every 3 years?
Participation in multidisciplinary groups to respond to survey Corrective action plans.
What are post survey workgroups?
Violations can result in lawsuits from patients or employees, as well as legal action from government agencies
What are legal ramifications?
Term for foregoing a direct CMS survey, hospitals and other healthcare providers can achieve Medicare certification through an accreditation survey conducted by an organization that CMS has approved. This means the accredited organization is considered compliant and is eligible to receive federal payments from Medicare and Medicaid
What is Medicare Conditions of Participation (CoPs)?
This survey, triggered by reports of potential violations, focusing on specific concerns raised by patients, staff, or other sources.
What is a complaint or grievance survey?
Survey conducted by CMS when there is a specific concern about a healthcare facility’s compliance with regulations. These surveys are typically unannounced and focus on investigating complaints, serious incidents, or potential violations of Medicare Conditions of Participation (CoPs).
What is a For-cause survey?
This group is responsible to interface and support the JHH Regulatory department's oversight of state and federal regulations as they apply to JHH.
Who are the JHH Quality Improvement -Patient Safety staff?
Non-compliance can erode public trust, making it harder for hospitals to attract patients and maintain partnerships
What is reputation damage?
Each department utilizes tools in preparation for survey readiness.
What are unit tracers?
This survey, is conducted after a previous survey identified deficiencies, ensuring corrective actions have been implemented.
What is a Revisit Survey?
Hospitals must navigate complex legal frameworks during surveys and to address any deficiencies or violations found, including; but not limited to, if a hospital disagrees with survey findings, to address deficiencies and prevent recurrence.
What is a Plan of correction (PoC)?
Centralized hub designed to manage regulatory surveys efficiently. It serves as the nerve center for coordinating responses, tracking compliance issues, and ensuring smooth communication between hospital leadership and surveyors.
What is a hospital survey command center?
Struggling to meet compliance requirements can divert resources away from patient care and strategic planning
What is operational inefficiencies?
The federal agency within the U.S. Department of Health and Human Services (HHS) who oversee federal healthcare programs. It plays a crucial role in shaping healthcare policy, ensuring regulatory compliance, and improving healthcare quality across the country. It also enforces standards for long-term care facilities, clinical laboratories, and health insurance portability
Who is The Centers for Medicare & Medicaid Services (CMS)?
This survey is thorough, planned, and organized. The organization hopes to receive a special award for this survey
What is a designation survey?
Timeline hospitals typically have to submit a Plan of Correction (PoC) after receiving a Statement of Deficiencies (CMS-2567). The PoC must outline corrective actions, timelines, and responsible parties to address the deficiencies
What are 10 calendar days? (not business days)
This survey is used by patients regarding their perspective on hospital care and can impact hospital ratings and reimbursement.
What is the hospital consumer Assessment of Healthcare Providers and Systems (HCAHPS)?
Hospitals that do not comply with CMS regulations risk losing their ability to participate in Medicare and Medicaid programs.
What is loss of Medicare/Medicaid Eligibility?