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Questions and Answers from The Greeley Company “Survey Hot Spots” Online Learning

On December 6, 2018 The Greeley Company held a national online seminar covering the top 20 Joint Commission and the top 22 CMS citations in recent years. (Follow this link to view this free webinar.)

This post covers the questions posed by the webinar audience, along with Greeley’s response.


Question: Will we receive a copy of these slides?

Question: Is there a fee for future webinars?

  • Answer: Some yes, some no. There are two types of Greeley online learning opportunities: Premium and Standard. There is no charge for Greeley’s Standard presentations, like the ‘Survey Hot Spots’ online learning. However, our Premium series includes downloadable, editable model policies and procedures, customizable slide decks, monitoring tools, etc. There is a charge for these Premium sessions. The fee for Premium presentations is waived for participants in Greeley’s membership program. To view upcoming Premium and Standard webinars, go to https://info.greeley.com/greeley-training. For information on Greeley’s membership program, please visit https://greeley.com/what-we-do/accreditation-compliance-quality/greeley-membership-program/.

Question: Are there certain states that issue the majority of the IJ citations?

  • Answer: We don’t have reliable data about the true rate of CMS immediate jeopardy citations. Only about half of the deficiency statements (2567s) issued are eventually uploaded to the national database. We believe the rate of IJ’s is roughly the same across the country over time. However, as incumbents change in the CMS regions and state offices, so does that jurisdiction’s attitude toward “immediate jeopardy.” Those considerations not withstanding, the big “IJ” hitters remain California, Texas, New York, Florida and (for a reason that is unclear to us) Louisiana.

Question: We heard via an email validation surveys will be happening at same time as JC survey. Have you heard that?

  • Answer: Yes. CMS announced a pilot program whereby CMS (or state surveyors on behalf of CMS) will accompany the accrediting organization on a sample of their accreditation surveys. We are unsure of the beginning and end dates of this pilot. Remember that this process would only be on a sample (about 5%) of accreditation surveys.

Question: There is a large focus on hospitals which is the majority of people here. My question is did the data come from just hospitals or does it also include IJs from other types of facilities?

  • Answer: The CMS data we displayed referred to hospitals (including critical access and psychiatric hospitals). It would be a different list for long term care institutions and dialysis suppliers. We suspect that the hospital IJ list would pertain to ambulatory surgical centers as relevant, meaning an emphasis on disinfection/sterilization and temperature and humidity. However, we did not carefully review ASC data. The links listed below will bring you to our separate posts addressing suicide prevention, contract monitoring, restraint, medication security and infection control.

Question: Should screening for suicidality be documented for all patients or only if certain criteria is met? Answer >

Question: What is the best evidence-based suicide screening tool for pediatric patients? Answer >

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 >

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

Question: You said that orders for non-violent restraints no longer need to be renewed every 24 hours? Answer >

Question: Can you go into more detail about what the regulations require for medication storage. In our facility, pharmacy insists that any and all medications be locked unless under 24/7 observation. This focus has even included pharmacy provided baby formula, eye drops, and other miscellaneous items kept at ambulatory settings that are supplied through pharmacy. Answer >

Question: Does food storage include staff refrigerators or only refrigerators with patient items? Answer >

Question: What is the focus when it comes to endoscope reprocessing? Answer >


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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