KGC Service provides regulatory and accreditation assistance world-wide for healthcare facilities physical environment compliance. CMS, DNV-GL, TJC, ACHC/HFAP, DOH, and CARF are just a few of the entities we assist healthcare organizations prepare for.
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The majority of surveys begin with a Physical Environment/Environment of Care "Document Review" session of the Life Safety and Critical Utility Systems documentations and records. This can make a tremendous difference in an organization's survey outcome by the setting the tone for how well numerous components in organizational physical environment are being maintained and tracked. By having organized and streamlined documents and records it allows you as an organization to insure all required inspection, testing, and maintenance of critical systems are being completed in a timely and complete manner, therefore giving a surveyor some comfort level that you are meeting the requirements of that specific entity
Many times all documentation and records are referred to just simply as "Documents". This is not true in most definitions, and certainly not when it comes to preparing your organization and fulfilling requirements. This can also create confusion for your staff when being questioned by a surveyor during an already stressful time.
Think of "documents" as instructions. This would be policies, procedures, contracts, preventative maintenance orders, OEM recommendations, etc. This is what you are instructing your internal staff, as well as external vendors, to perform day to day as part of fulfilling their duties or contracts. For example, you have a procedure of 10 items required for testing a certain piece of equipment. A document is the instruction to perform these tasks.
Think of "records" as the proof of completion of your documents. These are inspection and testing logs, completed preventative and corrective work orders, vendor records for performing contracted maintenance or testing, etc. Using the same example above, these records would be the proof that all 10 of those items were performed during this equipment testing procedure.
KGC provides documentation and record design services to assist your organization in designing organized, efficient, and streamlined documentation and records services. Services can range from providing education in this process, to turn-key design of manuals in hard copy or electronic format providing the required information to successfully display inspection, testing, and maintenance activities in order to insure ease of facility review, as well as ease of presentation for your survey entities. The design is such that no matter who is displaying and/or reviewing the documentation it can be done with ease and confidence. Be ready for your next survey, not scared of it!
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During this crucial time it is important to insure your continued ability to be reimbursed from CMS once the pandemic settles and you are trying to recover and get back to normal operations. When alterations are made to your facilities and/or you need to use alternate facilities (a tent outside the ED, or an area of your facility not designed for patient treatment, for example) you may not be meeting the requirements of the Conditions of Participation (CoP). By not meeting these requirements you can possibly lose your ability to bill for reimbursements through the Medicare and Medicaid programs. CMS has issued a few blanket waivers that cover many clinical and physical environment type issues, and many states have been approved for waivers through the 1135 waiver process covering specific needs.
However they may not cover many of the physical plant items such as the inability to complete certain required fire, utility, and/or medical equipment testing for varied reasons. Whether you use a blanket waiver provided, an approved state 1135 waiver, and/or the hospital acquired 1135 waiver process, it is critical to keep detailed documentation, and keep your Emergency Command Center operating in some manner throughout the event.
If you need assistance sifting though what is covered under blanket or state approved waivers, what you may need in order to request an 1135 waiver through the SSA program, what needs to be documented, or assistance completing any of the required actions, please do not hesitate to contact us for guidance and assistance.
For a link to CMS blanket waivers:
For Link to State Waivers approved:
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