Accreditation & Survey Preparation

Please read the attached PDF before delving into Survey Training Essentials Toolket (STET) files. It contains a short booklet on how to use and sort through STE tools

• STET CMS: This category provides examples and tools to assist in
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The Centers for Medicare and Medicaid Services (CMS) is the arm of the federal government that has oversight for the Medicare and Medicaid funding programs, regulates the quality of healthcare, and promotes healthcare system efficiency, quality, and beneficiary awareness of benefits.

CMS...

GOVERNING BODY:

• Can have a single governing body for multiple hospital system
• MD membership is allowed on the govern board

MEDICAL STAFF:

• Can have a single medical staff for multiple hospital system
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Use this checklist to validate compliance or opportunities for improvement.

CMS surveys are unannounced, but you should be familiar with the Conditions of Participation, determine compliance and implement actions to correct any issues.  You should also understand the process that occurs during a survey and actions to take after a survey.  The checklist will...

Example A – Condition of Participation from the State Operations Manual (SOM)  Appendix A – Hospitals

Tag A- 0449

§482.24 (c) – Standard:  Content of the Medical Record

The medical record must contain information to justify admission and...

Accreditation Questions for Ongoing Survey Readiness

The following folder contains quiz questions to help accreditation professionals coach staff and provide education on new and revised standards/Elements of Performance (EP) for continuous survey readiness. The questions are based on...