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  • Question: Surveyors have cited us for standards, such as contracted services, and are inconsistent with content of this webinar…. Is this where negotiation with surveyor is necessary?
  • Question: Regarding contracted services, would physician contracts fall into this?

Contract MonitoringOn December 6, 2018 The Greeley Company held its annual “Survey Hot Spots” national webinar. Feel free to view our free “Hot Spots” webinar in case you missed the live session.

Among the questions raised during the webinar were two related to a “hot spot” that has challenged hospitals across the country: contract monitoring.

Contract monitoring remains a frequently cited topic during CMS and accreditation surveys. It’s the 13th most common CMS citation related to “Immediate Jeopardy” termination actions. As a result, Greeley will be offering a Premium webinar that covers the contract monitoring standard in the near future.

The attendee’s questions about contract monitoring during the “Hot Spots” session and our answers are below.

Return to Hot Spots Q and A post.


[One of the topics covered in the wide-ranging “Hot Spots” webinar was contract monitoring. We briefly covered the three common myths about the contract monitoring requirement, myths that are perpetuated through inconsistent interpretations of the requirements for many years. This brief discussion lead to the following question.]

Question: Surveyors have cited us for standards, such as contracted services, and are inconsistent with content of this webinar…. Is this where negotiation with surveyor is necessary?

  • Answer: Great question.

Part 1: Working with the surveyor/survey agency

We have a standard approach that works well when surveyors cite standards incorrectly (in opposition to the true requirements). This will be covered in an up and coming online learning series on “Taking control of survey findings.”

Some standards are confusing, even to surveyors. As a result, many findings turn out to be inaccurate. We had one recent experience where a survey report with 60+ findings was whittled down to only two findings once we were able to review the report carefully with the survey agency. This is not a criticism of the surveyors or the agency, it’s just the way things work when there are thousands of pages of requirements, some of which are not as clear as one would like.

The intricate details of how to take control of survey findings, including our proven approach to successfully dealing with inaccurate or unclear findings, will be the subject of one of our upcoming Simplify and Comply Premium web offerings.

Part 2: About contracting

The standards that relate to contracting are confusing and very often misunderstood. Because of its placement in the “Governing Body” Condition of Participation, this issue comes up frequently.

We will go through the actual requirements in detail and help you walk the surveyor (any surveyor) through your process to show it complies with the actual regulations during your next survey. We highly recommend our April session on Dialysis and Contracting if this is an issue for you.

Part 3: Risk Assessment

Greeley recommends documenting a brief (one page) risk assessment for controversial issues like contract monitoring, restraint, and medication security. These risk assessments 1. document the actual regulatory and accreditation requirements, 2. review the literature (when relevant), 3. review your quality and risk data related to the issue (if any), and 4. draw a measured, good faith conclusion about the organization’s position with respect to the issue at hand.

A risk assessment is a very effective way to diffuse a controversy and level the playing field during a survey. We will provide model risk assessments during our contracting session, our discussion about medication security (“Common Medication Management Challenges”), our restraint program and other highly-cited and frequently-misinterpreted subjects. Look for registration postings here.

Question: Regarding contracted services, would physician contracts fall into this?

  • Answer: In most situations, yes.

The contracting standard applies to hospital-provided patient care and services (NOT supplies). If the hospital is contracting with a physician (group) to provide patient care services on behalf of the hospital, it would fall under this requirement.

There may be exceptions. For example, if the hospital is giving physicians a bonus for participating in meetings or serving on call (an existing obligation as a member of the self-governing Medical Staff), one could argue (in the risk assessment, see above) that those arrangements don’t fall under the contracting standards.

We will have a cheat sheet of covered and non-covered services in the Dialysis/Contracting educational event.

Surveyors are “all over the board” regarding contract monitoring. It seems each surveyor has their own take on the issue. Some individual surveyors seem to change their position over time. Such is to be expected when the actual standard lacks clear guidance.

That’s why it’s good to have a “risk assessment” document available for contract monitoring. As described in our answers to the restraint and medication security questions this risk assessment includes excerpts from CMS, accreditation and state requirements and a justification for the approach taken for your organization. These documents do wonders to level the playing field during surveys.

We will document our position during the Dialysis/Contracting session in great detail and give you a winning position regardless of which way the winds of the survey blow.


The Greeley Company team looks forward to helping you solve these difficult problems in the months and years to come. For more information about how Greeley can help accelerate solving your challenges with practical solutions, you may contact us at 1.888.749.3054, email us at info@greeley.com or complete the form below to start the conversation.

Let’s start the conversation.

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