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This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe.

An inside look at a CMS Life Safety CodeĀ® survey

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September 1, 2010

Your hospital just completed its Joint Commission survey and now you have another team of surveyors knocking on your door.

It’s a team from your state health department conducting a follow-up or validation survey on behalf of the Centers for Medicare & Medicaid Services (CMS) to ensure your hospital’s compliance with the Conditions of Participation (CoP).

Part of that survey will be a review of your Life Safety Code® (LSC) compliance. So what can you expect? Henry Kowalenko knows firsthand as the supervisor of the Design Standards Unit in the Division of Health Care Regulation at the Illinois Department of Public Health, where he’s been conducting and overseeing LSC surveys for the past 17 years.

Kowalenko shared his experience along with advice on how to have a successful survey at the 4th annual Hospital Safety Center Symposium, May 6 in Las Vegas.

Why CMS conducts surveys

CMS requires compliance with the LSC as one of the CoPs. The Code of Federal Regulations (CFR) outlines all of the CoPs that hospitals must comply with to receive funding through the Medicare program. CFR 482.41(b) requires hospitals to comply with the 2000 edition of the LSC.

CMS adopted the 2000 edition of the LSC as of March 11, 2003. Facilities with plan approvals or that were constructed after that date are considered new buildings under the LSC. If you added on to your original hospital, it can be a gray area, and it’s up to the surveyor whether to survey you as a new or existing occupancy, Kowalenko says.

Hospitals must demonstrate their compliance with all of the CoPs with accreditation by one of three accreditors—The Joint Commission, the American Osteopathic Association, or Det Norske Veritas Health Care, Inc.—or through an inspection by their state survey agencies that includes the department of public health or public safety or the state fire marshal.

The validation survey

If your hospital undergoes a Joint Commission survey, CMS requires validation of accrediting agencies’ findings. Validation surveys are scheduled within 60 days of the accreditation survey; however, only 2% of facilities are surveyed within a fiscal year, so not every hospital receives this follow-up survey. In Illinois, for example, only four hospitals will receive a validation survey per year.

Who gets selected for a validation survey? Kowalenko says the decision is made by CMS, not the states. “All we get is a memo” telling the department which facilities to survey, he says. In his time as a surveyor, he has been in some hospitals three times, whereas others he has never inspected.

If CMS selects your facility for a validation survey, the survey team will review all of the CoPs. These surveys are also provider number–specific, so surveyors can inspect any of your buildings that share your provider number. If the state receives a complaint about one of your buildings, all of your buildings are subject to survey. 

Other occupancies, such as areas for physical or occupational therapy, billing under your hospital’s provider number are subject to an LSC survey for their occupancy classification, Kowalenko says. They may be surveyed as business occupancies under Chapter 38 or 39 of the LSC, depending on whether they are new or existing buildings.

Surveyors will survey facilities built prior to March 11, 2003, under Chapter 19 of the LSC, “existing healthcare occupancies.” Surveyors will survey facilities (buildings, additions, renovations, etc.) completed after that date under Chapter 18, “new healthcare occupancies.”

All CMS surveys are unannounced. However, you know that if you have an accreditation survey, CMS could do a validation survey within 60 days.

Your hospital just completed its Joint Commission survey and now you have another team of surveyors knocking on your door.

It’s a team from your state health department conducting a follow-up or validation survey on behalf of the Centers for Medicare & Medicaid Services (CMS) to ensure your hospital’s compliance with the Conditions of Participation (CoP).



This is an excerpt from a member-only article. To read the article in its entirety, please login or subscribe.

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