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What deficiencies would you cite and why? And how would you correct them?

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April 26, 2020

by A.J. Plunkett (aplunkett@decisionhealth.com)

You be the surveyor.

The following information was taken from a CMS Form-2567 “Statement of Deficiencies” posted online by the federal agency under its Quality, Certification and Oversight Reports (QCOR) group.

The website—https://qcor.cms.gov/hosp_cop/HospitalCOPs.html—was announced in 2018 as a way for Medicare to put more pressure on accrediting organizations (AO) and healthcare providers to improve patient safety by highlighting facilities with what it calls “recent substantial deficient practice.”

The reports are usually from within the previous six months, and the search matrix shows whether the surveyors declared an immediate jeopardy and if the survey was because of a complaint, a recertification, or validation of an AO’s performance.

Read the following information. See if you can cite the same A-tag deficiencies that CMS surveyors did using the federal agency’s State Operations Manual (SOM), Appendix A, with interpretive guidelines to enforce Medicare Conditions of Participation. The report findings are included at the end of this article.

You be the surveyor.



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