Audits and Compliance
To prepare your facility for an upcoming accreditation or Federal/state survey, Murer Consultants can assist your facility by conducting an on-site survey to determine documentation and clinical compliance to determine readiness. To avoid costly delays in initial certification or arduous plans of correction, Murer will provide a multi-disciplinary team of on-site surveyors, which can review and perform:
- Organizing and governing documentation;
- Governance structure;
- Medical staff credentialing and HR files;
- Key policies and procedures;
- Environment of Care and Life Safety documentation.
- Patient tracer activities;
- Patient medical records and charting documentation;
- Director-level and staff interviews;
- Patient interviews.
In addition to providing a comprehensive written evaluation of opportunities for improvement, Murer Consultants will also work closely with administration and clinical leadership to counsel and resolve identified deficiencies on-site by providing daily updates and following the written evaluation to assist with implementation of recommendations.
PLAN OF CORRECTIONS
Following an on-site survey, state, regional, and accreditation agencies issue a Statement of Deficiencies report identifying findings. This document contains a listing of deficiencies cited by the surveying State Agency or Regional Office as requiring correction. The Statement of Deficiencies is based on the surveyors’ knowledge and interpretation of applicable regulations.
Following issuance of the Statement of Deficiencies, the healthcare organization must prepare a Plan of Corrections (POC) within a designated timeframe identifying how the facility will correct the deficiencies. The POC is the organization’s opportunity to demonstrate how substantial compliance will be attained.
The Plan of Correction must include the statements reflecting the facility’s plan for corrective action and the anticipated time of correction. Effective completion of a POC often requires communication with the surveying agency and comprehensive assessments of facility operations.
Murer Consultants assists healthcare organizations to prepare and implement an effective Plan of Corrections through offering the following services:
- Survey Exit Conference participation
- Initial POC strategy coordination
- Communication with survey staff
- Timely follow up with regulatory agencies
- Verification of POC due dates
- Interpretation of cited regulations and deficiencies
- Methods of Correction identification
- Strategy implementation