Keep required documents up to date and ready for surveyors, and have someone within the hospital leadership team available to come in on short notice once your hospital is within six months of its triennial survey date.
Have a plan of action to correct as many deficiencies as possible before the survey team leaves your facility, recommends a compliance manager at a Midwest hospital that was surveyed earlier this spring.
As in past years, CMS is concerned about the number and severity of deficiencies found by accrediting organizations (AO) compared to those found during CMS validation surveys at the same hospitals shortly thereafter.
Expect accrediting organizations (AO) to focus more on the physical environment, patient rights, infection control, governing body leadership, and anesthesia services. And also expect more condition-level findings.
In August 2022, a Joplin, Missouri, woman who was 17 weeks pregnant suffered a placental abruption, or loss of amniotic fluid, and sought care at a local hospital. When that hospital said it could not save her...
Establish an incident response team to handle decisions about high-risk pregnancy cases that may present dilemmas in your hospital’s emergency department (ED) as states continue to pass more restrictive abortion laws.