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Quarterly Hospital Compliance Survey Analysis

By: Dean Dorton | February 17, 2022

State Agencies and Accrediting Organizations monitor compliance with Medicare’s Conditions of Participation for Hospitals by conducting unannounced surveys. Hospital Compliance personnel can use this data set to identify common areas of deficiencies, trends and specific circumstances for each deficiency. This blog explores the most recent update that was posted in December 2021.

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State Agencies and Accrediting Organizations monitor compliance with Medicare’s Conditions of Participation for Hospitals by conducting unannounced surveys. The Centers for Medicare and Medicaid Services (CMS) publishes and updates a dataset with all Statements of Deficiencies identified during these surveys on a quarterly basis. The most recent update was posted in December 2021.

Hospital Compliance personnel can use this data set to identify common areas of deficiencies, trends and specific circumstances for each deficiency. Surveyors group deficiencies by which Condition of Participation was not met. Use the interactive report above to explore trends and changes.

General Observations

  • The overall number of surveys conducted decreased in 2020 and 2021 compared to the prior 3 years due to the COVID-19 pandemic.
  • Survey rates vary dramatically by state in each year—but also over time. Certain states have seen an increase in survey activity resulting in deficiency findings.
  • Survey deficiencies roughly correlate with the Hospital’s CMS Star Rating—with 5-Star rated hospitals averaging 1.7 deficiencies per survey in our dataset, whereas 2-Star rated hospitals averaged 2.5 deficiencies.
  • Non-profit hospitals comprise roughly two thirds of all hospitals surveyed in 2021. Proprietary for-profit hospitals made up about 20% of all hospitals surveyed in 2021.  Both of these hospital ownership types were significantly more likely to be surveyed than government-owned hospitals.  There is also a marked difference in the average number of deficiencies per survey between for-profit (2.5/survey) and non-profit (2.2/survey) hospitals.

Let’s take a closer look at the Top 10 deficiency areas from the past 5 years:

Restraints and Seclusion
Restraints and Seclusion deficiencies topped the list for each of the past 5 years. These findings were around the policy not being followed correctly, training around utilization, credentials for using these measures, and proper application.

Patient Rights: Care in a Safe Setting
Deficiencies in this area can span a wide range of hospital operations. Some specific findings in this area include:

  • Failing to properly launder and store linens;
  • Failing to perform daily checks of emergency Cardiopulmonary Resuscitation carts;
  • Failing to use red arm bands to indicate patients with identified medication allergies; and
  • Failing to notify the patient’s family and other care team members of aspirations that occurred when a Speech Language Pathologist conducted a swallow study.

These findings highlight the threats to patient safety that a wide range of hospital operations can harbor. Compliance and internal audit professionals would be wise to document and evaluate controls in areas that may seem secondary to direct patient care processes.

RN Supervision of Care
Common reasons for these types of deficiencies were nursing staff failure to complete pain assessments in accordance with physician orders for narcotic pain medications and failing to document ongoing RN supervision of nursing services provided to patients.

Patient Rights
Frequently cited deficiencies involving patient rights are failing to have or follow documented grievance policies, failing to keep patients—particularly psychiatric patients—safe from harm, and improper use of restraints and seclusion. Other deficiencies in this area include consent forms, admission forms, and discharge forms/planning not being in the correct language, presented to the patient, or discussed with them in general.

Compliance with 489.24
42 CFR §489.24 details the requirements hospitals with Emergency Departments must comply with. Deficiencies in this area frequently involve situations where a hospital failed to provide stabilizing treatment within its capacity prior to transferring a patient.

Medical Screening Exam
EMTALA requires hospitals with Emergency Departments to perform a Medical Screening Exam (MSE) conducted by qualified medical staff. Common deficiencies related to MSEs are:

  • Patients who presented to the ED ultimately leaving without an MSE due to long wait times.
  • Psychiatric patients not receiving an appropriate MSE.
  • Patients needing specialty care—notably obstetric care—not receiving an appropriate MSE from on-call providers.
  • The MSE being conducted by a person who is not considered qualified medical staff as stated in the hospital’s bylaws.

Infection Prevention
Deficiencies related to hospitals’ infection prevention practices spiked during the beginning of the COVID-19 pandemic. Common deficiencies noted in this area involve improper cleaning of respiratory equipment, not following isolation procedures, and trash/soiled areas in ‘clean’ sections of the hospital. Administrative inaction can also impact this area—namely, if vendors are not required by the facility to submit required infectious disease immunization or testing records.

Nursing Services
Nursing services deficiencies often stem from lack of documented assessments and follow up nursing care to address conditions such as pressure ulcers, behavioral health risks, and administration of pain medication.

Administration of Drugs
Administration of drugs deficiencies often involve incorrect or missing documentation of the administration of pain medication. Physician orders for these drugs may require an assessment to be conducted in order to determine the correct drug and dosage amount to be administered. Other drugs requiring an assessment—such as insulin—are also at greater risk for administration errors and ultimately patient harm.

Nursing Care Plan
Nursing care plan deficiencies often center on a lack of assessment and subsequent documented care for areas of care such as:

  • Fall Risk
  • Skin Integrity
  • Psychological Needs

Data Sources
Survey Data: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals
Hospital General Information Data: https://data.cms.gov/provider-data/search?theme=Hospitals

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