An Overview of Hospital Surveys

An Introduction to Hospital Surveys

Hospital Surveys:

A hospital survey is an evaluation of a hospital to determine the hospital’s compliance with state rules and federal regulations. The survey evaluates the hospital on such areas as nursing services, medical staff, dietary services, infection control, medical records, governing board, quality assessment and improvement, medical services, and physical environment.

Pursuant to Indiana Code 16-21, hospitals must be licensed. The Indiana State Department of Health is the licensing authority and has adopted rules for the operation of hospitals. The state rules may be found at 410 Indiana Administrative Code 15. Hospital surveys evaluate the hospital for compliance with these rules.

Medicare certification is under the authority of the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS). The federal regulations (Conditions of Participation for Hospitals) are found at 42 Code of Federal Regulations 482. Federal certification surveys and federal complaint surveys evaluate the hospital for compliance with these regulations.

Surveyors:

Surveys of Indiana hospitals are conducted by public health nurse surveyors and medical surveyors from the Indiana State Department of Health (ISDH) Division of Acute Care. Surveyors from the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) will occasionally participate in or conduct a survey. A majority of the hospital surveyors are registered nurses. Surveyors are experienced medical professionals and receive extensive training in hospital rules and regulations. Every surveyor is required to complete a CMS training program on hospital regulations and survey principles and procedures. Surveyors receive additional training throughout the year on the latest medical advances and updates to rules and regulations.

The Survey Process:

The survey process varies depending on the type of survey. Surveys may take only a few hours or last a week. Most all surveys are unannounced. Surveys generally include surveyor visits to the licensed hospital and a sample of off-site hospitals, agencies, or services operated under the license. During a survey, ISDH surveyors will tour the hospital, interview staff, and review patient records and other documents to determine compliance with state rules.

At the conclusion of the survey, surveyors prepare a report of their findings. A separate survey report is prepared for state and federal surveys. The survey report lists and describes all violations of state rules or federal regulations.

If deficiencies are cited on a survey, the hospital may be requested to complete a plan of correction on how and when they will achieve compliance with each deficiency and who will be responsible to ensure the corrections are made and will not reoccur in the future. The hospital submits the plan of correction to the ISDH within fifteen (15) days of the issuance of the survey report. The ISDH reviews and approves the plan of correction.

Types of Surveys:

There are numerous types of hospital surveys. These include:
• state licensure surveys
• state and federal complaint surveys
• accreditation surveys
• federal Medicare certification surveys
• post-survey revisit surveys
• preoccupancy surveys
• initial surveys
• life safety code survey

The following is a brief description of a few of the common hospital surveys.

State Licensure Surveys

Indiana Code 16-21 requires that every Indiana hospital be licensed. The Indiana State Department of Health (ISDH) is designated as the licensing authority. The ISDH conducts a state licensure survey at each licensed hospital approximately once per year.

The licensure survey is a comprehensive review of the hospital and the hospital’s compliance with state rules (410 Indiana Administrative Code 15). State licensure surveys are conducted by a team of ISDH surveyors. The survey is unannounced. A state licensure survey is usually completed in one to four days. The survey includes surveyor visits to the licensed hospital and a sample of off-site hospitals, agencies, or services operated under the license. During a licensure survey, ISDH surveyors will tour the hospital, interview staff, and review patient records and other documents to determine compliance with state rules.

Many hospitals voluntarily submit themselves for accreditation by a hospital accreditation association. If a hospital is accredited, the hospital may substitute the accreditation survey for the state licensure on-site survey. In years when an accreditation survey is performed, there may not be a state licensure survey conducted by the ISDH.

Federal and State Complaint Surveys

Any person may file a complaint with the ISDH about a hospital. The ISDH investigates all complaints. Complaints may be filed in person at the ISDH, in writing, by telephone, or by email. The toll-free complaint number is 1-800-246-8909. Instructions for submitting a complaint by email are found in the ISDH Regulatory Services Web site under “contact us.” Complaints are prioritized and scheduled for investigation based on their potential to place the health and safety of patients at risk. Complainants are informed (except anonymous complainants) upon receipt of the complaint by the surveyor and at closure of the complaint of the findings of the investigation.

A complaint survey is a focused survey reviewing the specific allegations of the complaint. The purpose of a complaint survey is to determine if the hospital is compliant with the state licensure rules (410 Indiana Administrative Code 15) and/or Conditions of Participation for hospitals (42 Code of Federal Regulations 482-489). A complaint survey is unannounced and the name of the complainant is not disclosed to the hospital. During the course of a complaint survey, surveyors may expand the scope of the survey if additional problems are observed. Complaint surveys are generally completed by only one or two surveyors and last a few hours to a day. Similar to the licensure survey, surveyors will visit the hospital, interview staff, and review records to determine compliance with state rules and federal regulations.

If in the course of investigating the complaint allegations a violation of state or federal rules or regulations is found by surveyors, the complaint is said to be “substantiated with findings.” These findings would be reported on the survey report issued at the conclusion of the survey.

Accreditation Surveys

While state rules do not require hospitals to be accredited, many hospitals voluntarily apply for accreditation from the Joint Commission for Healthcare Organizations (JCAHO), the American Osteopathic Association (AOA), or other accreditation organizations. Accreditation surveys are performed by the accreditation association once every three years. Accreditation is granted to the hospital if the hospital meets the standards of a private accreditation organization.

Section 1861(e) and 186(1) of the U.S. Social Security Act allows institutions accredited as hospitals by the JCAHO and AOA to be deemed to meet the Conditions of Participation for Hospitals. The ISDH also accepts the JCAHO or AOA inspection report in lieu of a state licensure on-site survey. In years when an accreditation survey is performed, there may not be a state licensure survey conducted by the ISDH.

Federal Certification Surveys

Federal Medicare certification surveys are conducted to determine hospital compliance with the Federal Conditions of Participation for Hospitals. For non-accredited federally certified hospitals, a federal Medicare certification survey is completed once every three years. A federal certification survey may also be completed if the Center for Medicare and Medicaid Services (CMS) finds the hospital to be out of compliance with a federal condition of participation and CMS requests that a certification survey be completed.

In the case of a hospital that is accredited, a hospital that meets accreditation standards is deemed to have met the Federal Conditions of Participation based on the accreditation survey. In that situation, the accreditation survey replaces the federal certification survey. Accredited hospitals will therefore likely not have a federal certification survey. If the Hospital Consumer Report indicates that the federal certification survey was “not applicable,” this indicates that the hospital is accredited and an accreditation survey was performed in lieu of a federal certification survey.

If a federal certification survey is performed, it is very similar to the state licensure survey except that it evaluates the hospital on federal regulations rather than state rules. During a federal certification survey, the surveyors will tour the hospital, interview staff, and view patient records and other documents to determine compliance with the Conditions of Participation for Hospitals. Noncompliance with the Conditions of Participation for Hospitals will result in issuance of a survey report specifying that the hospital did not meet a specific regulation.