Publication

California Hospital Survey Manual
Details new state survey process effective March 2016 and outlines complaint investigation process

Overview

The surveyors have arrived, unannounced, at your hospital. What do you do first? What will the surveyors do?

The California Hospital Survey Manual can help hospitals prepare for the survey process, and explains who the surveyors are and how they conduct their surveys. It covers the different types of surveys and possible outcomes, and:

  • Reflects CDPH changes effective March 2016, and details the survey process from start to finish
  • Provides tips on how to achieve a successful survey
  • Outlines tasks that must be done after the survey
  • Describes the laws surveyors use to assess compliance
  • Discusses surveyor rights and restrictions regarding access to peer review and attorney-client privileged materials
  • Includes charts and instruction sheets to calculate penalties CDPH may assess

The California Hospital Survey Manual is the only hospital survey manual that is specific to California and explains both state and federal requirements.

Topics include:

  • Introduction and Background
  • State Surveys
  • Federal Surveys
  • Tips for Achieving a Successful Survey
  • After the Survey
  • Sample Forms and Appendixes
  • List of Acronyms
  • Index                           

A must-have for licensing and accreditation professionals and compliance officers, recommended for legal counsel and risk managers.

(Third Edition, August 2015)

Contents

Chapter 1: Introduction and Background

  • State licensing — CDPH
  • Federal certification — CMS
  • Accreditation — TJC, AOA/HFAP, DNV Healthcare

Chapter 2: State Surveys

  • CDPH Licensing & Certification organizational structure and staffing
  • Types of state surveys, including CALS, complaint surveys, Patient Safety Licensing Surveys (PSLS), and Medication Error Reduction Plan (MERP) surveys
  • Which laws are state surveyors assessing compliance with?
    • Health and Safety Code, Title 22
  • Overview of surveyors’ procedures, the State-2567 (Statement of Deficiencies and Plan of Correction)
  • Possible survey outcomes, including immediate jeopardy, penalties

Chapter 3: Federal Surveys

  • CMS organizational structure and staffing
  • Types of federal surveys, including certification, validation, complaint surveys
  • Which laws are federal surveyors assessing compliance with?
    • Medicare Conditions of Participation, State Operations Manual, Interpretive Guidelines
  • Overview of surveyors’ procedures
    • Entrance conference, what to provide the survey team
    • Sample size and selection
    • Observation, interviews, record review by surveyors
    • Exit Conference
  • Possible survey outcomes, including condition-level vs. standard-level deficiency, immediate jeopardy, penalties, notice of termination
  • CMS-2567 (Statement of Deficiencies and Plan of Correction)

Chapter 4: Tips for Achieving a Successful Survey

  • Establish a Survey Readiness/Response Team
  • Train the licensing, certification and accreditation (LCA) team and hospital staff
  • Perform mock surveys
  • How to interact with surveyors, what to do during the survey
  • Checklist for exit conference

Chapter 5: After the Survey

  • Communicating survey results to governing body, employees, medical staff, media
  • Developing immediate corrective action steps and the plan of correction
  • Appealing penalties

Commands