Accreditation & Survey Preparation

A list of all current CMS CoPs for hospitals. It comes with some additional info on the CMS survey process too. It’s also available on the CMS website at https://www.cms.gov/Regulations-and...

A full edition of Briefings on Accreditation & Quality, a  HCPro newsletter on healthcare regulations and quality. Contains articles on Immediate Jeopardy, Life Safety Code clarifications, and a Accreditation 101 Q&A.

Last minute check for organization to use when surveyors arrive to rapidly remedy any areas of non-compliance

Project management tool to help the accreditation coordinator monitor compliance activities.

The Federal Emergency Management Agency offers this checklist to use as you review your orders of command succession, which is required for your emergency preparedness planning.

Surveyors continue to focus on the monitoring of contracted services. This article and accompanying checklists shows you how to get on top of it.

Use forms such as these to develop a list of the clinical contracts that Joint Commission surveyors might ask to review, along with the non-clinical contracts the CMS has shown an interest in.

A checklist to see if staff are using the checklists you give them

An article on high reliability and The Joint Commission’s ORO 2.0 assessment tools and resource library.

When visiting a hospital, surveyors use this worksheet to confirm an organization’s compliance with the QAPI CoPs. Use it to test your facility before surveyors arrive.