1. Allen, Nancy E. BSN, RNC, CMC

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Q: Sometimes we feel blindsided by a survey. Our clinical staff gives good care and our patients love us.


If your organization has ever received a deficiency, something has been missed. Too often in my travels throughout the United States and its territories as a surveyor or as a consultant, I see trends where gaps in compliance occur. During an analysis of an organization, I may hear from an administrator or clinical manager a statement such as yours-"We have a 5 Star on the Medicare Compare web site so I know we are giving good care."


Those statements may or may not be true. Patients may love their clinicians, but if the plan of care is not accurate, the plan of care is not followed, coordination of care is not occurring nor the physician being alerted to significant changes in condition, that is not "good" or compliant care. A 5 Star Rating on the Medicare Compare website comes directly from information provided by the Outcome and Assessment Information Set or other documentation. Often when there is a 5 Star Rating, an effective software or person who corrects or "fixes" documentation inconsistencies prior to sending the documentation to the Centers for Medicare and Medicaid Services is in use. At times, the rating does not reflect the actual care and corresponding documentation found in the patient record. When taking a deeper dive in the clinical documentation, one may find multiple Medicare Conditions of Participation out of compliance in spite of a 5 Star Rating.


Blindsided Prevention

One of the first questions surveyors or a consultant may ask when trends of noncompliance are found is to see the regulations that are in use. The state and federal regulations are the foundation of a government licensed or certified organization. If an organization is accredited, the accreditation standards must also be met. Often there is a search by the administrator or clinical manager to find them and/or what is produced is not current. How can one be or stay in compliance if the "rules" are not known?


Systems: Are there systems developed in the organization based on the regulatory rules to ensure compliance? Are daily operations proactive or reactive? Does one have to "Get Ready" when the survey window time rolls around? Compliance should be so interwoven into our daily tasks that we stay "Survey Ready."


Checks and Balances: Last, but not least in this abbreviated synopsis of "Meeting the Target of Compliance" is the following: There must be an implementation of checks, balances, and objective audits to ensure sustained compliance. Too many times it has been heard by a surveyor or consultant when deficient findings are presented, "That cannot be, our software is supposed to be keeping us in compliance!" A software or other system is just a tool. It takes those constant checks and balances to ensure systems are efficient and in compliance. It is important to remember it is not just about being in compliance to pass a survey or get good ratings on the Medicare Compare website. The "rules" for clinical care and operations are the minimum standards that must be met to deliver the quality care our patients so richly deserve!