CMS Termination Letters: What they mean and what to do if you get one (Infographic)

While it’s not something any hospital wants to acknowledge, the threat of receiving a CMS Statement of Deficiencies (CMS Form 2567) with Notice of Immediate Jeopardy or Notice of Termination is a reality. Hundreds of hospitals receive such notice every year. Because hospitals must be in compliance with all CoPs to continue participation in the Medicare… [Read More]

Long-Term Partnership Enhances Safety Program Efficacy and Compliance


A Midwest regional hospital with 350+ beds has been working with The Greeley Company for over eight years to support their physical environment survey readiness activities. The organization has faced increasing attention on the management of the physical environment by The Joint Commission, CMS, and state regulatory agencies. It has also become a rather complex organization,… [Read More]

Utilizing The Greeley Membership Program for TJC Survey Prep

As this rural, 225-bed tertiary care facility and teaching hospital was preparing for their Joint Commission survey, they sought to leverage onsite consulting assessments with offsite membership resources to optimize their state of readiness. The combination of services this client received as part of The Greeley Membership Program enabled leadership and staff to overcome ongoing survey challenges…. [Read More]

Sustainability Framework Improves Compliance

A 300-bed tertiary care facility and teaching hospital with a large complexity of service sought The Greeley Company’s assistance in remediating the process elements causing repeated failures to clear a specific Condition of Participation. Once on site, Greeley consultants found a number of areas causing the facility’s noncompliance with the specific condition. The organization did not have… [Read More]

Simplification Leads to Compliance Excellence

Although this large, tertiary healthcare system in New England has a strong, active internal accreditation readiness program, it has an ongoing relationship with The Greeley Company to objectively evaluate its compliance with both CMS and The Joint Commission. The organization makes significant use of Greeley’s aggregate experience with accreditation updates and challenges. Greeley consultants help the… [Read More]

Resolving Infection Control Challenges from the Ground Up

A medical center had very specific infection control issues it sought to overcome, specifically related to high-level disinfection processes and sterile processing functions. Compounding these issues was a lack of policies and procedures for these areas. The organization had previously been cited by CMS for issues regarding both endoscope cleaning and central sterile processing. After examining… [Read More]

Physical Environment Issues Top Citation Lists: Appropriate responses, policies improve results

During its triennial Joint Commission survey, an 80-bed hospital located an hour outside a major southwest metropolitan area was cited for a number of Environment of Care and Emergency Management issues. The survey was to be followed by an Evidence of Standards Compliance (ESC) survey, during which The Joint Commission would validate that the client had… [Read More]

The Compliance Myth: How You Might be Jeopardizing Quality and Satisfaction


Many compliance-related activities that exist in hospitals today are carried out based on the mythological belief that these things must be done to maintain the strict requirements set forth by regulating bodies such as CMS, The Joint Commission, and others. Hospital businesses are undertaking these efforts and expenses based on the myth instead of the… [Read More]

How “Leaning” Your EMR Improves Quality, Safety, Efficiency and Regulatory Compliance

We have all had beliefs we held to be true, only to find out at some point in the future that those beliefs were myths. And most of us have experienced or witnessed the crippling effects that the belief “more is better” can have. Steve Bryant, Senior Vice President and Managing Director of The Greeley Company, understands how regulatory myth, overinterpretation, and… [Read More]

CMS Termination Letter: What to Expect and How to Prepare


If your hospital has received a Statement of Deficiencies (CMS Form 2567) with Notice of Immediate Jeopardy or Notice of Termination, it has been determined that your hospital has a condition-level deficiency. This means your hospital is not in substantial compliance with one or more of the CMS Conditions of Participation. Condition-level deficiencies are more serious… [Read More]