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Ascension Health at St. Joseph Hospital CMS Survey Repairs

Project Overview

Surveys by the Centers for Medicare & Medicaid Services (CMS) have become a major concern for today’s healthcare facilities. Once, 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.

The Challenges

Recently DHS conducted a survey to determine Medicare Conditions of Participation compliance at Ascension Health – St. Joseph Hospital. This put the hospital in a position to develop, execute and document a plan of correction within 45 days — a very tight timetable considering that 20 of those days are used creating the plan of correction and getting it approved by DHS.

The Solutions

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.

The team also began communicating with the multiple levels of administration that needed to be coordinated if we were to gain access to areas of the hospital where corrections needed to be implemented. Areas like operating, MRI and radiology room are very rarely unoccupied and can’t afford much downtime.

To help organize and expedite the many fixes, the team utilized PlanGrid, a tool normally used for punch lists (final to do list) on construction projects, to document the status of every last deficiency.

The Results

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.

While the work went on, we were continuously compiling documentation to turn over to DHS in order to close out the deficiencies. PlanGrid also put up-to-date, real time information at the fingertips of the entire team.
Ultimately JP Cullen successfully led the effort to develop, execute and document corrections for more than 60% of the cited deficiencies that needed to be completed within the 45-day deadline, helping Ascension Health – St. Joseph Hospital avoid losing their accreditation.

Due to material lead times and architectural/engineering redesign, the remaining 30% deficiencies were corrected within 90 days and 10% of the items will be completed within one year.

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