CMS SURVEY TOOLKIT: PREPAREDNESS CHECKLIST

This checklist serves to provide assistance in preparedness for unannounced regulatory surveys. These hot-button items can be checked off quickly in each area to prepare for the unannounced regulatory surveyors’ review. It is important to be aware of and follow your hospital policy when considering certain checklist items, such as appropriate items at workstations.

I. GENERAL CONSIDERATIONS
CONDITION OF PARTICIPATION (PATIENT RIGHTS): A hospital must protect and promote each patient’s rights.
CONDITION OF PARTICIPATION (PHYSICAL ENVIRONMENT): The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment, and for special hospital services appropriate to the needs of the community.
CONDITION OF PARTICIPATION (INFECTION CONTROL): A hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.
II. PATIENT RIGHTS
PATIENT RIGHTS IS A CONDITION OF PARTICIPATION: A hospital must protect and promote each patient’s rights. Note these requirements:
  1. A hospital must inform each patient, or their representative, of their rights.

  1. Hospitals must establish a method to promptly address patient grievances. This method must be provided to the patient in writing.

  1. The patient has the right to participate in the formulation of their plan.

  1. The patient can have a family member or representative with them.

  1. The patient has the right to formulate advanced directives for their care.

  1. The patient has the right to have a family member, their representative, or their PCP promptly notified upon their admission to the hospital.

The patient has the right to direct verbal and written communications in their primary language preference.
Copies of Patient Rights are available for distribution.
Signage is in place and visible in public area(s).
III. PATIENT ABUSE
See Patient Rights Condition of Participation.
Patients will be free from abuse, including but not limited to undue restraints or seclusion. Any restraints allowed should be administered by trained staff and should only be imposed to ensure the immediate physical safety of staff, the patient, or others.
IV. PHYSICAL ENVIRONMENT
PHYSICAL ENVIRONMENT IS A CONDITION OF PARTICIPATION: The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment, and for special hospital services appropriate to the needs of the community.
There must be back up power in all ICUs, stairwells, and all operating, emergency and recovery rooms. Battery lamps and flashlights must be provided elsewhere.
There must be facilities for emergency gas and water supply.
V. INFECTION CONTROL
INFECTION CONTROL IS A CONDITION OF PARTICIPATION: A hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.
Staff can demonstrate hand washing.
Staff can demonstrate the use of personal protective equipment (when and how to use).
Staff can demonstrate the standard precautions on airborne, droplet, or contact precautions when entering an isolated patient room.
VI. MEDICAL NECESSITY
The most current version of the ABN is being used.
All required fields on the ABN are present.
VII. MSP AUDIT AND EDUCATION
MSP Policy & Procedure is documented and reflects current practice for registering Medicare beneficiaries.
Employees receive annual MSP Education.
Demonstrate that all employees have received MSP Education.
All employees can understand what to do when an ABN is needed and the patient is unable to provide their information.
VIII. ADVANCED DIRECTIVES
Patient education on Advanced Directives is available for distribution.
IX. CHARITY CARE
X. EMTALA
EMTALA statement clearly posted in the Emergency Department?

NAHAM CMS SURVEY TOOLKIT PREPAREDNESS CHECKLIST 1

Last Updated: March 27, 2013