Implementation of CMS Focused Survey Process

PDF Version of BQA 02-009 (PDF, 5 KB)

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Date: March 19, 2002 DSL-BQA 02-009

To: Hospitals HOSP 03, Critical Access Hospitals (CAH) CAH 02

From: Jane Walters, Chief, HSS

Via: Susan Schroeder, Director, Bureau of Quality Assurance

The purpose of this memo is to inform hospitals that the Centers for Medicare and Medicaid Services (CMS) has directed the Bureau of Quality Assurance (BQA) to implement the new Focused Validation Survey process for accredited hospitals. The purpose of the CMS directed validation survey is to evaluate the premise that a hospital accredited by JCAHO or AOA does, in fact, meet the Medicare Conditions of Participation for health and safety.

CMS continues to select hospitals for validation surveys on a random basis. However, instead of evaluating all of the Conditions of Participation as was the practice, CMS may direct BQA to look at a smaller number of the Conditions of Participation. In the case of the focused validation survey, BQA will no longer announce the survey as is done for full validation surveys. Instead, a letter of notification of the survey will be delivered to the hospital no more than 24 hours before the survey is to begin. The process for conducting the full validation survey has not changed.

It is anticipated that the focused validation survey will be less encompassing than the full validation survey, and that the survey team will complete the survey in a shorter amount of time. Hospitals will continue to receive written statements of deficiencies and hospitals will be asked to provide a plan of correction for those deficiencies.

Please direct questions concerning this process to Juan Flores, Supervisor, Health Services Section (replaced by Jan Heimbruch, (608) 243-2086).

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