General Survey Protocol

• CAH will not receive advanced notice of survey.
• The surveyor will assess compliance with all areas under CCN.
• CAH must grant immediate access upon a reasonable request or can terminate Medicare.
• CAH cannot refuse to permit copying of records or information.
• A CAH is required to comply with CoPs to receive Medicare/Medicaid payment.
• The surveyor will look at telemedicine contracts.
• The surveyor will not withhold areas of concern until the conclusion.
• The surveyor cannot touch or examine patients and if concerned about bedsores, bruised, or incontinence will ask staff to remove or will be present while physical exam is done.
• The surveyor may need to make copies of some of the EHRs but will try and not print entire records.
• The surveyor may ask what happens if the computer system goes down.
  • How do you register a patient, transfer, or admit?
  • How do you order or get lab results?
• All team members must review their findings and concerns and be prepared to discuss them during the daily meeting.
• The surveyor will determine if corrective actions make it unlikely for the deficient practice to reoccur.
• The surveyor will not delay a survey to wait for additional staff to arrive.
• CAH to make sure surveyors have access to copiers.
• If CAH uses an EHR or electronic policy and procedures, surveyors will need access to printers.
• The surveyors can make an extra copy of every document that surveyors copy.
• The surveyor will not provide the hospital with a list of the records reviewed or patients, staff or visitors they meet.
• CAH staff can accompany surveyors, if they do not provide the answers or interject.