Accreditation and CMS Survey Preparation
Each healthcare facility faces its own challenges
when it comes to accreditation or survey prep. Preparing for an accreditation or CMS survey — which should occur at least six months prior to the expected survey timeframe — can be a challenging and difficult process for healthcare facilities. Surveys are unannounced and usually take place every three years. There is a period of three months that the agencies or organizations will visit the facility, but specific dates are not revealed.
PIPC accreditation and CMS survey preparation services, provided under the direction of our team of experts, ensure your personnel now what to expect such as the current standards and the proper processes for safe patient care.
PIPC works with an organization's leadership to update policies and procedures, so they are in line with nationally recognized guidelines. By conducting an infection prevention mock survey, PIPC identifies aspects of the operation that are not compliant with rules, regulations and standards, and then works with leadership to help ensure these issues do not lead to survey deficiencies.
PIPC provides your facility with a detailed report of findings and suggestions for improvement as well as ongoing guidance following completion of the mock survey.
If your organization recently underwent a survey that revealed deficiencies, contact PIPC to learn about our services for Plan of Correction development.
Survey Background
Accreditation of acute-care hospitals began with The Joint Commission (TJC), formerly known as The Joint Commission on Accreditation of Healthcare Organization (JCAHO). TJC accredits more than 20,000 health care organizations and programs nationwide, and the Centers for Medicare & Medicaid Services (CMS) recognize TJC accreditation, as well as accreditation from other organizations, as a condition of licensure and reimbursement.
Several newer organizations have joined the acute-care hospital accreditation process: DNV GL and Healthcare Facilities Accreditation Program (HFAP). Several hospitals, particularly specialty hospitals, such as behavioral health, surgical specialty and critical access, have chosen to be accredited by these newer agencies.
Long-term care facilities are surveyed by the state department responsible for assuring patient safety, while most ambulatory surgery centers (ASCs) acquire "deemed status" from CMS through accreditation agencies specifically geared towards ASC services. These agencies include the Accreditation Association for Ambulatory Health Care (AAAHC), TJC and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
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