A Value Proposition White Paper
CMS surveys take
over your life if you’re a dialysis facility administrator. For the four to five days the surveyors, usually
from the Department of Health Services (DHS) are in the unit, you get very little
else done. Then they leave and the work really starts.
How much of everyone’s
time this will take depends on how many V tags are cited. The DHS surveyors will find deficiencies even
in the best run facilities. And the Interpretive
Guidelines make it clear that many identified problems can be cited under more than
one V tag. Many surveyors will cite a single
identified problem in multiple locations, multiple V tags. How much time it will
take to address problems is also dependent upon the seriousness of the citations. Are they Condition Not Met level or Standard Not
Met level? Is the issue patient safety or
housekeeping? Overall, the more V tags, the
more serious, and the more time consuming to fix.
*Note that time
is described as Personnel Hours. Personnel
Hours = Number of hours needed for the activity times the number of people involved
in each activity. The estimates are approximate
of course.
|
Post-CMS-Survey
|
Personnel Hours*
required for activity.
|
|
Activity
|
>10 V tags
|
< 10 V tags
|
|
Organize the CMS/DHS summation conference notes into a presentable
format. Prepare for meetings (outlined
below) to communicate preliminary findings.
|
2
|
1
|
|
Meet with dialysis
leadership to review the preliminary findings.
|
4
|
2
|
|
Meet with other
key stakeholders (physicians and other care providers, staff, organizational leadership)
to communicate preliminary findings.
|
10
|
5
|
|
Begin to develop
plans of correction for identified problems.
|
4
|
2
|
|
Receive and
review Statement of Deficiency (CMS-2567).
|
1
|
1
|
|
Develop with
the dialysis leadership team a detailed Plan of Correction to the Statement of
Deficiency, including a realistic time line for correction completion.
|
80
|
20
|
|
Prepare a written
Plan of Correction response to each V tag given in the Statement of Deficiency
for submission to DHS within 10 business days. Review the response with leadership team members
to assure accuracy of proposed correction and time line.
|
16
|
4
|
|
CMS/DHS re-survey
visit, including conference and interview time, documentation preparation, review
and discussion. If minimum deficiencies,
DHS will sometimes by-pass re-survey visit for documentation submission only.
|
32
|
16
|
|
Organize the
CMS/DHS re-survey summation conference notes into a presentable format. Prepare for meetings (outlined below) to communicate
re-survey findings.
|
2
|
1
|
|
Meet with dialysis
leadership to review the re-survey findings.
|
4
|
2
|
|
Begin to develop
plans of correction for identified unresolved/new problems.
|
2
|
1
|
|
Receive and
review re-survey Statement of Deficiency.
|
1
|
1
|
|
Develop with
the dialysis leadership team a detailed Plan of Correction to the Statement of
Deficiency.
|
40
|
10
|
|
Prepare a written
Plan of Correction response to each V tag given in the re-survey Statement of
Deficiency for submission to DHS within 10 business days. Review the response with leadership team members
to assure accuracy of proposed correction and time line.
|
8
|
2
|
|
Implementation
of Plan of Correction for Deficiencies
|
80
|
80
|
|
Total Approximate Personnel Hours
|
286
|
148
|
Surveyors, whether CMS or your own, will find problems. Problems will need to be fixed. Fixing problems takes time. But the bottom line is that fewer V tags on the
CMS survey translates to less of the dialysis facility’s leadership time spent spinning
bureaucratic wheels doing paperwork, 138 fewer personnel hours in our rough sample. If the average salary for dialysis facility leadership
is $50, then -
Cost: 138 Personnel Hours x $50 = $6,900
