Audits and Surveys

Question 1

. What is the purpose of DaVita’s internal audit?

Answer 1

These audits are used to help facilities prepare and sustain survey readiness by adhering to our
policies and procedures and regulations.

Question 2

What prompts a visit from a surveyor? List six examples:

Answer 2

Complaint
Initial survey (for new facility)
Citation and are back for follow up
Routine survey
State Dept of Health (not meeting their inspection standards)
Communicable disease (outbreak)/Death at facility

Question 3

What are the Conditions for Coverage(CfC)?

Answer 3

• Requirements that providers and suppliers must meet to be CMS certified
• When met, allows providers to be paid for furnishing services to Medicare beneficiaries

Question 4

How many conditions for coverage are there?

Answer 4

17

Question 5

What are the three types of CMS Deficiencies?

Answer 5

Standard, Condition and Immediate Jeopardy

Question 6

Explain the standard type of CMS Deficiency:

Answer 6

Failure to meet the regulations in one or more areas

Question 7

Explain the Conditional type of CMS Deficiency:

Answer 7

o Many citations (deficiencies) in one area or “more serious”
o Must be corrected within 30-90 days
o Potential for decertification if not corrected

Question 8

Explain Immediate Jeopardy CMS deficiency:

Answer 8

o Potential for or actual harm to patient
o Survey /dialysis stops until immediate correction
o Written plan of correction (POC) usually handed to surveyor
o May have 23 days to correct or be decertified

Question 9

What are some examples of reasons for an Immediate Jeopardy (IJ)?

Answer 9

• A covered vascular access
• Not knowing the water room components
• Not performing water checks correctly

Question 10

Explain what is meant by a Culture of Safety

Answer 10

• ‘See it say it’- everyone has a responsibility to maintain a culture of safety and follow P&P.

Question 11

What is the purpose of the “Flash Tour”?

Answer 11

• Enables the surveyors to quickly assure patient safety prior to full audit.

Question 12

How to talk to a surveyor and what to do when surveyor observes you or asks questions.

Answer 12

• Be courteous, answer questions, if you are not sure - do not say ‘I do not know’- or ‘this is the way we do it’.
  You can voice - you are not sure about a process, but will follow up and find out.

Question 13

What is an example of what not to say to a surveyor?

Answer 13

• ‘Don’t care, that is just the way I do it’

Question 14

State 5 actions how you can assist in survey readiness:

Answer 14

• Be prepared
• Stay current on and follow P&P
• Assist with internal audits
• Maintain a culture of safety
• Participate in teammate meetings such as homerooms and core team meetings