Many folks don’t know that our Licensing division undergoes a periodic audit (survey) to look at compliance to our Federal contract with the Centers for Medicare Medicaid Services (CMS). This past week, 3 surveyors from the regional office of CMS came to review our Long Term Care and Medical Facilities areas. This survey centered on complaint surveys and their prioritization, initiation and investigation. This audit is much like the surveys the Division of Licensing performs on our licensees. There’s an “entrance” whereby the Surveyors explain why they’re here, what they’re going to look at and items that they’ll need in order to help them with their survey. Then there are a few days of what can be intensive record review, interviews with staff and other associated investigatory activity.
Then the Surveyors compile their information and hold an “exit” with the staff to review what they did, found and suggestions from the survey. During this, exit the staff finds out areas the Surveyor reviewed and if there are any areas they will need to improve upon (findings). CMS asks for a plan of correction where we would provide a description of how the issue(s) will be resolved, when they’ll be resolved and how we’ll maintain and monitor things.
Lots of hard work goes into preparing for these CMS visits. Thank you’s go to everyone who work in the Bureaus of Long Term Care Licensing and Bureau of Medical Facilities Licensing. It is truly a team effort as CMS looks at the field work/documentation of the Surveyors, the reviews of the Team Leaders and Bureau Chiefs and the documentation files etc. the Program Project Specialists and the Support Staff maintain. We don’t have our report back yet- but all indications are that we did well on our assessment.