Ascension SE Wisconsin Hospital
St. Joseph Campus CMS Survey Repairs

Surveys by the Centers for Medicare & Medicaid Services (CMS) have become a major concern for today’s healthcare facilities. At one point, accreditation surveys were all a healthcare facility had to worry about. However, today, with the revalidation surveys and increases in complaint survey activity, healthcare facilities now have to deal with the ever-present threat of a CMS survey. JP Cullen has collaborated with five different healthcare facilities in recent years to help a.) develop the plan for correction b.) correct the deficiencies, and c.) provide the necessary documentation to the Division of Health Services (DHS) and CMS to close out citations and eliminate the risk of accreditation loss.

On receiving the list of deficiencies from DHS, JP Cullen immediately began working on the paperwork, stating the specific nature of the corrective actions for each deficiency, setting reasonable completion dates for all deficiencies and detailing how the corrections will prevent recurrence. Once completed, the plan of correction forms were submitted to DHS for approval.

Concurrently, JP Cullen began working on the cited deficiencies they could to meet the 45-day deadline. Right away a 16-member team was created — field and office — and subcontractors were mobilized to ensure we would meet the extremely tight schedule.

Not only did we correct the cited deficiencies, but other deficiencies besides to ensure there would be no issues when DHS re-inspected the area. This was especially true in hard-to-access areas.