The CMS Life Safety Survey: Know the Process and Stay Vigilant
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Product Description:
AUDIO CONFERENCE ON-DEMAND
Sponsored by: Hospital Safety Center
Presented on Monday, February 28, 2011
Our experts break down the CMS life safety survey and appeal process
During this 90-minute audio conference, Greeley Company consultants Brad Keyes and Jim Murphy will walk you and your staff through which items are covered during a survey, and how the Life Safety Code® interacts with the CMS Conditions of Participation. Don’t let a small oversight turn into a full CMS validation survey. Sign your staff up today for proven strategies to help prepare for—and pass—your next CMS life safety survey.
At the conclusion of this program, participants will be able to:
- Explain how a CMS survey originates and the different types of CMS surveys
- Analyze the components of the CMS life safety survey process
- Formulate a plan for CMS survey follow up and dealing with findings
- Identify the differences between CMS and Joint Commission life safety surveys
TAKE A LOOK AT OUR AGENDA
- What is CMS?
- Medicare/Medicaid reimbursement authority
- Conditions of Participation (CoP) must be met
- What triggers a CMS Life Safety survey?
- Complaint surveys
- 5% of all accreditation surveys receive a follow-up validation survey
- News story of sub-standard care
- Who is involved in a CMS validation survey?
- Depends on size of hospital: Multiple architects, engineers, and other specialists
- Will also include: Medical professionals, nutritionists
- Length of stay depends on size of hospital: From a few days to a couple weeks
- What will be surveyed?
- Policies/procedures
- Verification of work practices
- Building tour
- Facilities will be surveyed under NFPA 101 Life Safety Code (LSC), 2000 edition
- Chapter 19 for existing hospitals constructed prior to March 11, 2003
- Chapter 18 for new buildings, additions, renovations completed on or after March 11, 2003
- Change from 2000 edition of LSC may occur with the 2012 cycle revision, but would not be approved until 2014 or so
- Life Safety survey process
- Look above ceilings at rated walls
- Examine mechanical rooms and storage rooms
- Trace paths of egress to the public way (outdoors)
- Exit interview
- Identify deficiencies cited
- Answer questions
- The CMS process
- Formal Statement of Deficiencies (SoD) report
- CMS form 2567 for non-life safety issues
- CMS form 2786 for life safety issues
- CMS sets termination of participation date
- Plan of correction (PoC)
- The plan to correct deficiencies must be in-depth and detailed
- Revisions to PoC are acceptable for valid reasons such as contractor delay, weather delay, etc.
- Include all ILSMs that will be implemented
- Follow-up “mini-surveys” will be made by the state agency based on the PoC
- Purpose is to verify progress on PoC and ILSM implementation
- Follow-ups will be unannounced
- Follow-up visits will focus on cited deficiencies
- Waiver process
- Know the waiver process
- Differences between CMS and TJC surveys
- CMS surveys are conducted by state agency representatives
- Length of survey and number of surveyors
- Different expectations of compliance with the LSC
- When state regulations differ with CMS LSC requirements
- State agency representatives sometimes will enter state deficiencies onto CMS SoD report
- Live questions and answer session
BONUS TOOLS INCLUDED IN YOUR MATERIALS PACKET:
In addition to the expertise and advice presented during this audio conference, you’ll also receive a slide presentation of the program materials and tools, including:
- Form 2786R—K-Tags form (CMS)
- Form 2567 (CMS)
- Sample waiver form
- Life safety assessment
- Additional forms/checklists
WHO SHOULD LISTEN:
Security directors/officers, safety directors/officers, emergency management directors, CEOs, facility managers, quality assurance staff, accreditation staff, survey coordinators and survey staff
ABOUT THE SPEAKERS:
Brad Keyes, CHSP, is a life safety consultant at The Greeley Company. He is a former life safety specialist for The Joint Commission. His expertise lies in the management of the environment of care, development of leadership effectiveness, and efficiency in work processes.
James Murphy, RA, NCARB, is a consultant with the Greeley Company, a division of HCPro, Inc., in Danvers, MA. He is a practicing architect with over 30 years experience in healthcare architecture and specializes in assisting hospitals with code compliance issues. In addition to consulting, Murphy brings years of practical experience in correcting code deficiencies. He is also active in developing CAD-based tools for use by hospitals in the on-going effort to maintain code compliance. Murphy is certified by the National Council of Architectural Registration Boards.
AUDIO ON-DEMAND:
In addition to the regular participation options for HCPro audio conferences we are pleased to offer another option, an audio on-demand. Audio on-demand allows you to download the program and play it back at your convenience through your computer or MP3 player. It’s also a perfect training tool for new staff or as a refresher for veteran staff.
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