Working with Our Smallest Hospitals to Provide Quality Care

Conditions of Participation Surveys

Project Summary

Federal and state agencies, including the Centers for Medicare and Medicaid Services (CMS), have established health and safety standards for health care facilities. These federal
requirements in the Medicare Conditions of Participation (CoP) provide facilities with written guidance to improve the quality of care, and to protect the health and safety of their patients. Compliance with these regulations and standards is tied to payment for services rendered to Medicare and Medicaid beneficiaries, as well as, in some cases, patients covered by private insurers.

As part of routine evaluations or complaints, representatives from CMS evaluate health care organization compliance with CMS regulations through unannounced site visits. In Vermont, these visits are conducted by the Department of Disabilities, Aging & Independent Living (DAIL), Division of Licensing and Protection (DLP). Deficiencies identified in these surveys by DLP can lead to significant mandatory remedial actions for
the hospital.

As part of the Medicare Rural Hospital Flexibility Grant Program (Flex), VPQHC visits Vermont’s small rural hospitals to review the quality-related regulations established by CMS. While the VPQHC site visits and mock surveys incorporate many of the same processes that DLP includes in their surveys, (such as regulatory compliance, policy compliance, medical record reviews, environmental evaluations, and staff interviews), the
process is non-punitive. Hospitals receive a thorough report from VPQHC, detailing the findings and recommendations from the site visit and mock survey.

Recommendations and Next Steps

In the changing health care environment, compliance with regulatory standards is challenging for hospitals, regardless of size. Continuing support for the smaller hospitals in identifying areas of opportunity and areas to focus their limited resources on will help the hospitals meet their goal of providing high quality, safe patient care.