Nursing homes and long-term care facilities that participate in Medicare and Medicaid programs are subject to regular annual surveys by the Centers for Medicare & Medicaid Services (CMS) to ensure compliance with federal regulations and standards.
Any failure to meet these requirements can result in serious consequences, including fines, legal action, or even loss of certification. This all falls under the umbrella of Immediate Jeopardy—a phrase that can strike fear into the heart of any healthcare provider. Some of the most common CMS survey deficiencies include infection control, accidents, quality of care/life, medication management, resident assessment, and staffing.
However, by implementing evidence-based practices, providing proper training to staff, and regularly evaluating policies and procedures, healthcare providers can take steps to avoid these deficiencies and provide the best possible care to their patients.
Check out our guide to mitigating immediate jeopardy risks!
Immediate jeopardy citations result from the most dire and serious findings in a CMS survey. Essentially, it means that a healthcare provider's noncompliance with CMS regulations has placed patients in immediate danger of serious physical and/or psychological injury, harm, impairment or death.
During a CMS survey, an official surveyor evaluates a healthcare provider's compliance with CMS regulations, policies, and standards. If the surveyors identify an issue that poses an immediate threat to patient safety, they may issue an immediate jeopardy citation. This citation requires healthcare providers to take immediate corrective action to remedy the issue and prevent further harm or potential further harm to patients.
Without a serious and proactive approach to resolving your facility’s issues, you will face fines, legal action, or even loss of Medicare or Medicaid certification. But by prioritizing patient safety and implementing training along with policies and procedures that comply with CMS regulations, healthcare providers can minimize the risk of immediate jeopardy citations and provide high-quality care to their patients.
Here are some of the most common CMS survey deficiencies and how to avoid them:
To avoid deficiencies in this area, make sure your staff are trained in proper hand hygiene and follow standard precautions, such as wearing gloves and gowns when necessary. Ensure that all medical equipment is properly cleaned and disinfected after each use.
Facilities must ensure they mitigate an environment free from accident hazards they can control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes individual resident hazards risk assessment including: identifying, evaluating/analyzing, implementing interventions, monitoring effectiveness and modifying interventions when necessary to prevent any unexpected or unintentional accidents.
A critical component of healthcare, CMS surveys often assess whether providers are meeting established quality standards. Implement evidence-based clinical protocols and guidelines, use performance metrics to measure outcomes, and see that all staff are trained in quality improvement methodologies and are actually implementing them on the floor.
Medication errors can have serious consequences for patients. As such, it’s vital to have robust medication management policies in place. Medication orders must be accurately recorded and verified, medication dispensing and administration practices must be followed correctly, and staff must be trained in identifying and reporting adverse medication events.
For long-term care facilities, CMS surveys often focus on resident assessment and care planning. To avoid deficiencies in this area, ensure that all residents are accurately assessed and that care plans are developed and routinely revised based on individual needs and preferences; this ensures that they remain appropriate and effective.
Adequate staffing levels are critical to ensure quality care and patient safety. Staffing levels must always be at an appropriate level for patient acuity/needs, and staff should be properly trained and supervised. Regularly evaluate staffing levels and adjust as necessary to ensure that patient needs are being met.
Maintaining compliance with CMS regulations is essential to delivering high-quality care and avoiding survey deficiencies. By implementing evidence-based clinical protocols and guidelines, providing proper training to staff, and regularly evaluating and adjusting policies and procedures, healthcare providers can minimize the risk of deficiencies and provide the best possible care to their patients.
CMS survey deficiencies can seriously hamper your facility’s ability to not only meet the needs of your patients, but also merely keep your doors open. Qsource is a certified Quality Improvement Organization. Our reliable and fully vetted processes can help you:
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