Did you know?
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?
Number of CMS Conditions of Participation (CoPs)
What is 24?
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 is required for deemed status or CMS recognition purposes.
What is an unannounced survey?
Timeline organizations who have earned and maintained the Gold Seal of Approval from the TJC and can expect an unannounced survey.
What is every 3 years?
Participation in multidisciplinary groups to respond to survey Corrective action plans.
What are post survey workgroups?
An action by CMS if an accredited organization is in violation of a CMS determined complaint investigation/validation survey resulting in loss of Medicare and/or Medicaid reimbursements.
What is loss of deemed status?
Term for foregoing a direct CMS survey, to achieve Medicare certification through an accreditation survey conducted by an organization that CMS has approved. Allows organization that is compliant, 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?
Timeline surveyors will most likely review performance improvement data
What is the past 12 months?
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?
Survey conducted by CMS when there is a specific concern about a healthcare facility’s compliance with regulations.
What is a for-cause survey?
Time from surveyor arrival devoted to planning for survey activities
What is the (1st) hour?
Centralized hub designed to manage regulatory surveys efficiently.
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, helps shape healthcare policy, ensures regulatory compliance, and improves healthcare quality across the country.
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).
What are 10 calendar days? (not business days)
Hospitals response to address any deficiencies or violations found or prevent recurrence, and/or if they disagree with survey findings.
What is a Plan of correction (PoC)?
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?