Accreditation and CMS Survey Preparation

Preparing for an accreditation or CMS survey — which should occur at least four months prior to the expected survey timeframe — can be a challenging and difficult process for healthcare facilities. Surveys are unannounced and usually take place every three years. There is a window of three months that the agencies or organizations will visit the facility, but specific dates are not revealed.

ICCS accreditation and CMS survey preparation services, provided under the direction of our team of experts, ensure your personnel are knowledgeable of current standards and understand the proper processes for safe patient care.

ICCS works with an organization's leadership to update policies and procedures so they are in line with nationally recognized guidelines. By conducting an infection prevention mock survey, ICCS identifies aspects of the operation that are not compliant with rules, regulations and standards, and then works with leadership to help ensure these issues do not lead to survey deficiencies.

ICCS provides your facility with a detailed report of findings and suggestions for improvement as well as ongoing guidance following completion of the mock survey.

If your organization recently underwent a survey that revealed deficiencies, contact ICCS to learn about our services for Plan of Correction development.

Survey Background
Accreditation of acute-care hospitals began with The Joint Commission (TJC), formerly known as The Joint Commission on Accreditation of Healthcare Organization (JCAHO). TJC accredits more than 20,000 health care organizations and programs nationwide, and the Centers for Medicare & Medicaid Services (CMS) recognize TJC accreditation, as well as accreditation from other organizations, as a condition of licensure and reimbursement.

Several newer organizations have joined the acute-care hospital accreditation process: DNV GL and Healthcare Facilities Accreditation Program (HFAP). A number of hospitals, particularly specialty hospitals, such as behavioral health, surgical specialty and critical access, have chosen to be accredited by these newer agencies.

Long-term care facilities are surveyed by the state department responsible for assuring patient safety, while most ambulatory surgery centers (ASCs) acquire "deemed status" from CMS through accreditation agencies specifically geared towards ASC services. These agencies include the Accreditation Association for Ambulatory Health Care (AAAHC), TJC and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).


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I wanted to thank you again for all of your advice and support. I thought you would like to know that we were visited by CMS and then three days later we were visited by Joint Commission. In the Joint Commission follow up, they stated that they had no findings. I have no doubt that you played a big part in that.

Sean Farley, MBA, CMRP, Director, Organizational Procurement, Virginia Mason Medical Center, written to ICCS President Phenelle Segal