Prepare For a CMS Audit In 5 Steps

Blogs | 4 Minute Read

There’s one event that can make even the most seasoned and successful of PACE directors uneasy: A letter from CMS announcing that their program will be audited.

Al’Asia Powell, Director of Quality and Patient Safety at a New Jersey PACE program operated by Inspira Health Network, has been in her role for more than seven years. But even she admits that such a letter can bring on “a sinking feeling.” To beat such feelings and sail through CMS audits, we spoke to Al’Asia about a five-step approach to meeting the challenge.

1. Complete a gap analysis

This should always be your first step. “You want to make sure that you understand what the regulatory requirements are, what you are responsible for, and what it is that any regulatory agency, including CMS, is looking for. You compare that to what your current practice and processes are.”

Another place to look for gaps is in the results of any previous audits. Look through your previous audit outcome to remind yourself of opportunities for improvement—and compare that to your ongoing gap analysis.

2. Make a plan

The second thing to do is make an action plan. That means you have to identify the key priorities. It also helps to group your priorities, such as:

  • Systemic challenges
  • Participant satisfaction issues
  • Participant care concerns

Now that you’ve identified key concerns, develop strategies to address those issues. And most importantly, track your progress in implementing your strategies. Use whatever tracking tools work for you, whether it’s an Excel spreadsheet or a notebook, as long as it does the job.

Al’Asia notes that it’s also important to identify people who will be directly involved in the process and lead efforts toward success. But she warns, make sure they are appropriately knowledgeable.

“If you have someone who is developing an action plan and is not the subject matter expert, it will impact your outcome.”

–Al’Asia Powell

3. Execution

In the execution phase, you bring all your information to the appropriate committees.

“Perhaps your Performance Improvement or Quality Committee. It may be some type of Council Environment of Care. We all have Environmental Care Committees, Compliance, Infection Control. These are the committees that will assist you with your audit prep,” Al’Asia says.

CMS provides the audit protocol. The document is available via the CMS website to all PACE organizations and includes compliance standards. Clear communication of these standards with key committees and staff members is essential to success. The better they understand the current state and the mandated outcome, the more effective your team will be.

4. Implementation

Implementation entails the ongoing review of your survey readiness tracker. Does it show that you are trending in the right direction? If not, do you need additional tools or action? You’ll get through the audit process just fine if you stay flexible, open minded, and attentive.

According to Al’Asia, “There may be a time where you have to pivot. Maybe you’re just not hitting the mark on a particular action item and so you need to focus more attention and effort there.”

5. Resolution

Finally, the time comes to review your outcomes.

You’ll need to make sure that your staff demonstrates the required competency as laid forth in the CMS compliance standards and your own action plan. It’s on you to validate that your team is capable of performing the required duties.

Some staff members may be uncomfortable with the kind of close observation required in this context, so make sure that they understand the rationale for close observation.

“It’s not a test. It’s an open forum for communication, for parties to explain exactly what they’re doing and why. Make sure you achieve that understanding with your staff.”

–Al’Asia Powell

A Final Word of Advice

There are a lot of resources available to those who want more advice on handling an audit. Al’Asia recommends visiting the National PACE Association website and searching out relevant e-communities.

“You can ask questions and receive responses from PACE organizations all across the nation,” she said. “CareVention HealthCare is a resource. And if you’re part of a larger system, connect with another quality director or compliance person or your operational leaders. They’ll be able to point you in the right direction.”

Finally, Al’Asia has this advice:

“You have to always be ready to embrace change. You can’t accept the mentality that ‘Well, this is the way we’ve always done it.’”

To learn more, listen to our podcast episode featuring Al’Aisa Powell.

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