Regulatory Role of Surveyor and Consultant

4018 - Regulatory Role of Surveyor and Consultant (Rev. 1, 05-21-04) (Also see §2727, and Appendix P – Section 9) The survey and certification process is intended to ascertain whether providers and suppliers meet program participation requirements. Therefore, the primary role of the surveyor is to assess the quality of care and services and relate those findings to statutory and regulatory requirements. When deficiencies are found in the course of a survey, the surveyor should explain to the provider what the deficiency is in terms specific enough to allow a reasonably knowledgeable person to understand why the requirement is not met. In many situations, the explanation of the deficiency itself provides the necessary information needed to correct the problem. This is not considered to be consultation. However, in some instances there may be several possible causes for the deficiency, and it is for these situations that the policy for not providing consultation is intended. It is not the surveyor’s job to examine the facility’s policies and procedures to determine or speculate on the root cause of deficiencies, or to sift through various alternatives to prescribe one acceptable remedy. In these situations, the provider is responsible for determining the most feasible and economical way of achieving compliance. On resurvey, the surveyor’s task is to ascertain whether compliance has been achieved and not whether the provider did what the surveyor recommended. Thus, in reviewing a proposed PoC, the SA reviews the plan only for effectiveness and timeliness. Surveyors should be willing to explain the requirements and why something is a deficiency. For example, if a provider is cited for maintaining incomplete clinical records, the surveyor is to specify what is missing, not why it is missing or what process is best for ensuring that the records are complete in the future. Under no circumstances should a data tag or a reiteration of the regulations be used as a substitute for an explanation. The SA staff should be willing to work with all groups in its State if such discussions or meetings lead to more meaningful surveys or an overall improvement in compliance by providers and suppliers.