Responding Effectively to Adverse CMS, State, and Accreditation Findings

Clinical Quality Insights

Condition-level findings are returning with more frequency and severity than ever before as regulators and accreditors return to the field. Surveyors are discovering significant compliance concerns and threatening hospitals with CMS termination as they realize their attention has not been on compliance over the last few years. Hospitals cannot afford to make promises they can’t keep in the Plan of Correction or, worse, damage their level of compliance by unnecessarily complicating clinical and environmental operations as they address individual findings. Key learning points included: 

  • Focus on the most frequent serious issues identified during State Agency / CMS “validation” surveys
  • Effectively manage the on-site survey process
  • Establish and maintain professional and mutually beneficial relationships with the regulators
  • Work with regulators to implement meaningful, sustainable, and efficient corrective action
  • Effectively manage and present evidence of corrective action
  • Maintain credibility with the survey agency by understanding and appropriately addressing underlying patient safety vulnerabilities 

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