Because CMS surveyors are given latitude in how to assess deficiencies, immediate jeopardy is always a risk. But there are ways to reduce your chances of receiving the worst citation.
Close oversight of day-to-day activities by the hospital board and management can go a long way toward avoiding immediate jeopardy, says Susan G. Kratz, JD, shareholder and chair of the healthcare practice group with the law firm Nilan Johnson Lewis in Minneapolis. The goal is to catch potentially serious problems before CMS does.
“Constantly reviewing the Medicare guidelines for the conditions of participation is an important strategy,” she says. “It also is important to have accountability for the staff responsible for monitoring compliance and reporting to the board how things are going.”
That oversight should be a primary focus for hospital leaders, says Ruth Ragusa, RN, vice president of organizational effectiveness at South Nassau Communities Hospital in Oceanside, NY.
“It’s about constantly looking at practice and policy, and closing the gap,” she says. “There are so many things the staff have to manage that it’s just human nature for them to miss something. Hospital leaders have to step in and close that gap with education and training.”
- Susan G. Kratz, JD, Shareholder and Chair, Healthcare Practice Group, Minneapolis, MN. Telephone: (612) 305-7699. Email: [email protected].
- Ruth Ragusa, RN, Vice President of Organizational Effectiveness, South Nassau Communities Hospital, Oceanside, NY. Telephone: (516) 632-3999. Email: [email protected].
