HACP QUESTIONS WITH COMPLETE
SOLUTIONS
Certification wProcess w- w✔✔Hospitals whave wsome woptions wwhen wit wcomes wto
wMedicare wcertification: w
• wA whospital wcan wbe wdirectly wcertified wby wMedicare w
• wA whospital wcan wbe waccredited wby wa wdeemed-status wprovider w
• wA whospital wcan wforgo wMedicare wcertification wentirely
Certification wProcess w- w✔✔ROLE wOF wTHE wSTATE wENFORCEMENT wAGENCY w
With wover w4000 whospitals wacross wthe wUnited wStates, wCMS wdoes wnot whave wthe
wmanpower wto wconduct won-site wsurveys. wTherefore, wCMS whas wceded wsurvey
wactivities wto weach wState. wThe wState wEnforcement wAgency w(SA) wis wusually wthe
wDepartment wof wHealth wor wsimilar wbody. wThe wSA wis wresponsible wfor: w
• wInvestigating wcomplaints wabout whospitals wand walleged wviolations wof wpatient
wrights wor wother wCoP' w
• wConducting wfull wvalidation wsurveys wof wa whospital's wcompliance wto wthe wCoP'. w
• wIssuing wreports wof wfindings wand wmonitoring wcorrective waction wplans w
• wRecommending wto wCMS wpotential wtermination wof wa whospital's wability wto
wparticipate win wMedicare wpayment wprograms
Certification wProcess w- w✔✔MEDICARE wCERTIFICATION wNUMBER w
Each whospital wis wassigned wa wunique wcertification wnumber wcalled wa wCCN. wThis
wnumber wis wused wby wthe whospital wfor wany wservice wunder wwhich wMedicare wis
wbilled. wCMS wwill wassess wa whospital's wcompliance wwith wthe wCoP wfor wall wservices,
wareas wand wlocations win wwhich wthe whospital wreceives wreimbursement wfor wpatient
wcare wservices wbilled wunder wits wCCN.
Certification wProcess w- w✔✔COMPOSITION wOF wTHE wSURVEY wTEAM w
The wState wEnforcement wAgency wdecides wthe wcomposition wand wsize wof wa wsurvey
wteam. wIn wgeneral, wa wsurvey wteam wfor wa wfull wsurvey wof wa wmid-size whospital
wwould winclude wtwo-four wsurveyors wwho wwill wbe wat wthe wfacility wfor w3 wor wmore
wdays. wEach whospital wsurvey wteam wwill winclude wat wleast wone wRN wwith whospital
wsurvey wexperience, was wwell was wother wsurveyors wwho whave wthe wexpertise
wneeded wto wdetermine wwhether wthe wfacility wis win wcompliance. wSurvey wteam wsize
wand wcomposition ware wnormally wbased won wthe wfollowing wfactors: w
• wSize wof wthe wfacility wto wbe wsurveyed, wbased won waverage wdaily wcensus; w
• wComplexity wof wservices woffered, wincluding woutpatient wservices; w
• wType wof wsurvey wto wbe wconducted; w
,• wWhether wthe wfacility whas wspecial wcare wunits wor woff-site wclinics wor wlocations; w
• wWhether wthe wfacility whas wa whistorical wpattern wof wserious wdeficiencies wor
wcomplaints; wand w
• wWhether wnew wsurveyors ware wto waccompany wa wteam was wpart wof wtheir wtraining
Certification wProcess w- w✔✔All whospital wsurveys ware wunannounced. wHospitals ware
wnot wprovided wwith wadvance wnotice wof wthe wsurvey.
Certification wProcess w- w✔✔SURVEY wACTIVITIES w
Arrival wby wthe wSurvey wTeam w
The wentire wsurvey wteam wshould wenter wthe whospital wtogether. wUpon warrival,
wsurveyors wshould wpresent wtheir widentification. wThe wteam wcoordinator wshould
wannounce wto wthe wAdministrator, wor wwhoever wis win wcharge, wthat wa wsurvey wis
wbeing wconducted. wIf wthe wAdministrator w(or wperson win wcharge) wis wnot wonsite wor
wavailable w(e.g., wif wthe wsurvey wbegins woutside wnormal wdaytime wMonday-Friday
wworking whours), wthey wwill wask wthat wthe wAdministrator wbe wnotified wthat wa wsurvey
wis wbeing wconducted. wThe wsurvey wwill wnot wbe wdelayed wbecause wthe
wAdministrator wor wother whospital wstaff wis/are wnot won wsite wor wavailable.
Certification wProcess w- w✔✔Survey wSchedule w
Unlike wthe wdeemed-status wagencies, wCMS wdoes wnot wprovide wa wtemplate wor wlikely
wsurvey wschedule wto whospitals. wThe wTeam wCoordinator wworks wwith wthe wother
wsurveyors wto wdetermine wwhere wand wwhen wvarious wactivities wwill wtake wplace.
wThere wis wno wset wagenda wor wschedule wof wactivities. wThe wamount wof wtime wspent
win wan warea wand wthe wspecific wactivities wthat woccur win wan warea ware wleft wto wthe
wsurveyor's wdiscretion.
Certification wProcess w- w✔✔The wnumber wof wpatient wrecords wreviewed wis wbased
won wthe wfacility's waverage wdaily wcensus. wThe wsample wshould wbe wat wleast w10
wpercent wof wthe waverage wdaily wcensus, wbut wnot wfewer wthan w30 winpatient wrecords.
Certification wProcess w- w✔✔The wnumber wof wpatient wrecords wreviewed wis wbased
won wthe wfacility's waverage wdaily wcensus. wThe wsample wshould wbe wat wleast w10
wpercent wof wthe waverage wdaily wcensus, wbut wnot wfewer wthan w30 winpatient wrecords.
Certification wProcess w- w✔✔On wany wMedicare whospital wsurvey, wcontracted wpatient
wcare wactivities wor wpatient wservices w(such was wdietary wservices, wtreatment
wservices, wdiagnostic wservices, wetc.) wlocated won whospital wcampuses wor whospital
wprovider wbased wlocations wwill wbe wsurveyed was wpart wof wthe whospital wfor
wcompliance wwith wthe wconditions wof wparticipation.
Certification wProcess w- w✔✔A wdeficiency wat wthe wCondition wlevel wmay wbe wdue wto
wnoncompliance wwith wrequirements win wa wsingle wstandard wor wseveral wstandards
wwithin wthe wcondition wor wwith wrequirements wof wnoncompliance wwith wa wsingle wpart
w(tag) wrepresenting wa wsevere wor wcritical whealth wor wsafety wbreach. wEven wa
wseemingly wsmall wbreach win wcritical wactions wor wat wcritical wtimes wcan wkill wor
, wseverely winjure wa wpatient, wand wrepresents wa wcritical wor wsevere whealth wor wsafety
wthreat.
Certification wProcess w- w✔✔THE wCMS wPLAN wOF wCORRECTION w
Following wthe wsurvey wa wstatement wof wdeficiencies w(Form wCMS-2567) wwill wbe
wmailed wwithin w10 wworking wdays wto wthe whospital. wForm wCMS-2567 wis wthe
wdocument wdisclosed wto wthe wpublic wabout wthe whospital's wdeficiencies wand wwhat wis
wbeing wdone wto wremedy wthem.
Certification wProcess w- w✔✔The whospital wis wrequired wto wsubmit wa wwritten wplan wof
wcorrection wto wthe wsurvey wagency wwithin w10 wcalendar wdays wfollowing wreceipt wof
wthe wwritten wstatement wof wdeficiencies. wThe wplan wof wcorrection wis wsubmitted won
wthe wForm wCMS-2567. wThe wrequired wcharacteristics wof wa wplan wof wcorrection
winclude: w
• wCorrective waction wto wbe wtaken wfor weach windividual waffected wby wthe wdeficient
wpractice, wincluding wany wsystem wchanges wthat wmust wbe wmade; w
• wThe wposition wof wthe wperson wwho wwill wmonitor wthe wcorrective waction wand wthe
wfrequency wof wmonitoring; w
• wDates weach wcorrective waction wwill wbe wcompleted; w
• wThe wadministrator wor wappropriate windividual wmust wsign wand wdate wthe wForm
wCMS-2567 wbefore wreturning wit wto wthe wsurvey wagency; wand w
• wThe wsubmitted wplan wof wcorrection wmust wmeet wthe wapproval wof wthe wState
wagency, wor win wsome wcases wthe wCMS wRegional wOffice wfor wit wto wbe wacceptable.
Condition wof wParticipation: wGovernance w- w✔✔If wa whospital wsystem whas wchosen
wto whave wone wbody wact was wthe wgoverning wbody wfor wmultiple wseparately wcertified
whospitals, wthis wdoes wnot walter wthe wfact wthat weach whospital wmust wseparately
wdemonstrate wcompliance wwith wthe wCoPs. wEach wseparately wcertified whospital
wmust wbe wseparately wand windependently wassessed wfor wits wcompliance wwith wthe
wCoPs, wthrough weither wState wSurvey wAgency wor wapproved wnational waccreditation
wprogram wsurveys. wThere wis wno wsurvey wof wa whospital w"system," wsince wthe
wMedicare wagreement wand wits wterms ware wspecific wto weach wcertified whospital.
Condition wof wParticipation: wGovernance w- w✔✔The wgoverning wbody wmust wtake
wactions wthrough wthe whospital's wQAPI wprogram wto: w
• wAssess wthe wservices wfurnished wdirectly wby whospital wstaff wand wthose wservices
wprovided wunder wcontract, w
• wIdentify wquality wand wperformance wproblems, wimplement wappropriate wcorrective
wor wimprovement wactivities, wand w
• wEnsure wthe wmonitoring wand wsustainability wof wthose wcorrective wor wimprovement
wactivities. w
The wgoverning wbody wmust wensure wthat wthe wservices wperformed wunder wa wcontract
ware wprovided win wa wsafe wand weffective wmanner.
SOLUTIONS
Certification wProcess w- w✔✔Hospitals whave wsome woptions wwhen wit wcomes wto
wMedicare wcertification: w
• wA whospital wcan wbe wdirectly wcertified wby wMedicare w
• wA whospital wcan wbe waccredited wby wa wdeemed-status wprovider w
• wA whospital wcan wforgo wMedicare wcertification wentirely
Certification wProcess w- w✔✔ROLE wOF wTHE wSTATE wENFORCEMENT wAGENCY w
With wover w4000 whospitals wacross wthe wUnited wStates, wCMS wdoes wnot whave wthe
wmanpower wto wconduct won-site wsurveys. wTherefore, wCMS whas wceded wsurvey
wactivities wto weach wState. wThe wState wEnforcement wAgency w(SA) wis wusually wthe
wDepartment wof wHealth wor wsimilar wbody. wThe wSA wis wresponsible wfor: w
• wInvestigating wcomplaints wabout whospitals wand walleged wviolations wof wpatient
wrights wor wother wCoP' w
• wConducting wfull wvalidation wsurveys wof wa whospital's wcompliance wto wthe wCoP'. w
• wIssuing wreports wof wfindings wand wmonitoring wcorrective waction wplans w
• wRecommending wto wCMS wpotential wtermination wof wa whospital's wability wto
wparticipate win wMedicare wpayment wprograms
Certification wProcess w- w✔✔MEDICARE wCERTIFICATION wNUMBER w
Each whospital wis wassigned wa wunique wcertification wnumber wcalled wa wCCN. wThis
wnumber wis wused wby wthe whospital wfor wany wservice wunder wwhich wMedicare wis
wbilled. wCMS wwill wassess wa whospital's wcompliance wwith wthe wCoP wfor wall wservices,
wareas wand wlocations win wwhich wthe whospital wreceives wreimbursement wfor wpatient
wcare wservices wbilled wunder wits wCCN.
Certification wProcess w- w✔✔COMPOSITION wOF wTHE wSURVEY wTEAM w
The wState wEnforcement wAgency wdecides wthe wcomposition wand wsize wof wa wsurvey
wteam. wIn wgeneral, wa wsurvey wteam wfor wa wfull wsurvey wof wa wmid-size whospital
wwould winclude wtwo-four wsurveyors wwho wwill wbe wat wthe wfacility wfor w3 wor wmore
wdays. wEach whospital wsurvey wteam wwill winclude wat wleast wone wRN wwith whospital
wsurvey wexperience, was wwell was wother wsurveyors wwho whave wthe wexpertise
wneeded wto wdetermine wwhether wthe wfacility wis win wcompliance. wSurvey wteam wsize
wand wcomposition ware wnormally wbased won wthe wfollowing wfactors: w
• wSize wof wthe wfacility wto wbe wsurveyed, wbased won waverage wdaily wcensus; w
• wComplexity wof wservices woffered, wincluding woutpatient wservices; w
• wType wof wsurvey wto wbe wconducted; w
,• wWhether wthe wfacility whas wspecial wcare wunits wor woff-site wclinics wor wlocations; w
• wWhether wthe wfacility whas wa whistorical wpattern wof wserious wdeficiencies wor
wcomplaints; wand w
• wWhether wnew wsurveyors ware wto waccompany wa wteam was wpart wof wtheir wtraining
Certification wProcess w- w✔✔All whospital wsurveys ware wunannounced. wHospitals ware
wnot wprovided wwith wadvance wnotice wof wthe wsurvey.
Certification wProcess w- w✔✔SURVEY wACTIVITIES w
Arrival wby wthe wSurvey wTeam w
The wentire wsurvey wteam wshould wenter wthe whospital wtogether. wUpon warrival,
wsurveyors wshould wpresent wtheir widentification. wThe wteam wcoordinator wshould
wannounce wto wthe wAdministrator, wor wwhoever wis win wcharge, wthat wa wsurvey wis
wbeing wconducted. wIf wthe wAdministrator w(or wperson win wcharge) wis wnot wonsite wor
wavailable w(e.g., wif wthe wsurvey wbegins woutside wnormal wdaytime wMonday-Friday
wworking whours), wthey wwill wask wthat wthe wAdministrator wbe wnotified wthat wa wsurvey
wis wbeing wconducted. wThe wsurvey wwill wnot wbe wdelayed wbecause wthe
wAdministrator wor wother whospital wstaff wis/are wnot won wsite wor wavailable.
Certification wProcess w- w✔✔Survey wSchedule w
Unlike wthe wdeemed-status wagencies, wCMS wdoes wnot wprovide wa wtemplate wor wlikely
wsurvey wschedule wto whospitals. wThe wTeam wCoordinator wworks wwith wthe wother
wsurveyors wto wdetermine wwhere wand wwhen wvarious wactivities wwill wtake wplace.
wThere wis wno wset wagenda wor wschedule wof wactivities. wThe wamount wof wtime wspent
win wan warea wand wthe wspecific wactivities wthat woccur win wan warea ware wleft wto wthe
wsurveyor's wdiscretion.
Certification wProcess w- w✔✔The wnumber wof wpatient wrecords wreviewed wis wbased
won wthe wfacility's waverage wdaily wcensus. wThe wsample wshould wbe wat wleast w10
wpercent wof wthe waverage wdaily wcensus, wbut wnot wfewer wthan w30 winpatient wrecords.
Certification wProcess w- w✔✔The wnumber wof wpatient wrecords wreviewed wis wbased
won wthe wfacility's waverage wdaily wcensus. wThe wsample wshould wbe wat wleast w10
wpercent wof wthe waverage wdaily wcensus, wbut wnot wfewer wthan w30 winpatient wrecords.
Certification wProcess w- w✔✔On wany wMedicare whospital wsurvey, wcontracted wpatient
wcare wactivities wor wpatient wservices w(such was wdietary wservices, wtreatment
wservices, wdiagnostic wservices, wetc.) wlocated won whospital wcampuses wor whospital
wprovider wbased wlocations wwill wbe wsurveyed was wpart wof wthe whospital wfor
wcompliance wwith wthe wconditions wof wparticipation.
Certification wProcess w- w✔✔A wdeficiency wat wthe wCondition wlevel wmay wbe wdue wto
wnoncompliance wwith wrequirements win wa wsingle wstandard wor wseveral wstandards
wwithin wthe wcondition wor wwith wrequirements wof wnoncompliance wwith wa wsingle wpart
w(tag) wrepresenting wa wsevere wor wcritical whealth wor wsafety wbreach. wEven wa
wseemingly wsmall wbreach win wcritical wactions wor wat wcritical wtimes wcan wkill wor
, wseverely winjure wa wpatient, wand wrepresents wa wcritical wor wsevere whealth wor wsafety
wthreat.
Certification wProcess w- w✔✔THE wCMS wPLAN wOF wCORRECTION w
Following wthe wsurvey wa wstatement wof wdeficiencies w(Form wCMS-2567) wwill wbe
wmailed wwithin w10 wworking wdays wto wthe whospital. wForm wCMS-2567 wis wthe
wdocument wdisclosed wto wthe wpublic wabout wthe whospital's wdeficiencies wand wwhat wis
wbeing wdone wto wremedy wthem.
Certification wProcess w- w✔✔The whospital wis wrequired wto wsubmit wa wwritten wplan wof
wcorrection wto wthe wsurvey wagency wwithin w10 wcalendar wdays wfollowing wreceipt wof
wthe wwritten wstatement wof wdeficiencies. wThe wplan wof wcorrection wis wsubmitted won
wthe wForm wCMS-2567. wThe wrequired wcharacteristics wof wa wplan wof wcorrection
winclude: w
• wCorrective waction wto wbe wtaken wfor weach windividual waffected wby wthe wdeficient
wpractice, wincluding wany wsystem wchanges wthat wmust wbe wmade; w
• wThe wposition wof wthe wperson wwho wwill wmonitor wthe wcorrective waction wand wthe
wfrequency wof wmonitoring; w
• wDates weach wcorrective waction wwill wbe wcompleted; w
• wThe wadministrator wor wappropriate windividual wmust wsign wand wdate wthe wForm
wCMS-2567 wbefore wreturning wit wto wthe wsurvey wagency; wand w
• wThe wsubmitted wplan wof wcorrection wmust wmeet wthe wapproval wof wthe wState
wagency, wor win wsome wcases wthe wCMS wRegional wOffice wfor wit wto wbe wacceptable.
Condition wof wParticipation: wGovernance w- w✔✔If wa whospital wsystem whas wchosen
wto whave wone wbody wact was wthe wgoverning wbody wfor wmultiple wseparately wcertified
whospitals, wthis wdoes wnot walter wthe wfact wthat weach whospital wmust wseparately
wdemonstrate wcompliance wwith wthe wCoPs. wEach wseparately wcertified whospital
wmust wbe wseparately wand windependently wassessed wfor wits wcompliance wwith wthe
wCoPs, wthrough weither wState wSurvey wAgency wor wapproved wnational waccreditation
wprogram wsurveys. wThere wis wno wsurvey wof wa whospital w"system," wsince wthe
wMedicare wagreement wand wits wterms ware wspecific wto weach wcertified whospital.
Condition wof wParticipation: wGovernance w- w✔✔The wgoverning wbody wmust wtake
wactions wthrough wthe whospital's wQAPI wprogram wto: w
• wAssess wthe wservices wfurnished wdirectly wby whospital wstaff wand wthose wservices
wprovided wunder wcontract, w
• wIdentify wquality wand wperformance wproblems, wimplement wappropriate wcorrective
wor wimprovement wactivities, wand w
• wEnsure wthe wmonitoring wand wsustainability wof wthose wcorrective wor wimprovement
wactivities. w
The wgoverning wbody wmust wensure wthat wthe wservices wperformed wunder wa wcontract
ware wprovided win wa wsafe wand weffective wmanner.
