Preparing Documentation for Health Facility Surveys

 

To: Licensed Health Facility Administrators From: The Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division The Colorado Department of Public Health and Environment (CDPHE), Health Facilities and Emergency Medical Services (HFEMS) Division, is committed to continually improving our survey processes to better serve Colorado's licensed healthcare facilities while ensuring compliance with applicable state and federal requirements. As part of a recent process improvement initiative, the Division evaluated opportunities to make the survey process more efficient for both healthcare providers and our survey staff. One area identified was the amount of time spent during surveys requesting and gathering documentation needed for review. To help streamline the survey process, we have developed standardized documentation lists based on facility type. We respectfully request that your facility prepare these materials in advance and have them readily available in a single location at the start of the survey whenever possible. While advance preparation of these documents is not a regulatory requirement, it is strongly encouraged as a best practice to help facilitate a timely, organized, and efficient survey. Our goal is to reduce the amount of time spent locating documentation during the survey, allowing both facility staff and surveyors to focus on the survey process itself. Requested Documentation Acute Care (ASC, Birth Centers, CCDOC, CCEC, FSED) Assisted Living Residences Home Care (Adult Day, HCA Class A & B, HHA, IHSS, PHS, Hospice) Nursing Facilities Intellectual & Developmental Disabilities (ICF,RCF) Having these materials organized and available at the beginning of the survey offers several benefits: Reduces time spent locating and retrieving documents throughout the survey. Allows surveyors to begin the review process more efficiently. Minimizes interruptions to facility staff during the survey. Helps shorten the amount of time surveyors need to remain onsite whenever possible. Please note that these documentation lists are intended to facilitate a more efficient survey process and represent the materials most commonly requested during a survey. Depending on observations made during the survey, staff interviews, complaint allegations, or other survey findings, surveyors may request additional documentation as necessary to complete the survey in accordance with applicable state and federal requirements. We recognize that every facility operates differently, and we appreciate your partnership in this effort. Your preparation and cooperation help us conduct surveys more efficiently while allowing both facility staff and surveyors to focus on what matters most ensuring the delivery of safe, high- quality care for Colorado residents. This initiative reflects the HFEMS Division’s commitment to being a Reliable, Efficient, Accountable, Compliant, and Helpful (REACH) partner to Colorado’s licensed healthcare providers while fulfilling our responsibility to protect the health and safety of the people we serve. Thank you for your continued partnership and commitment to quality. We appreciate your support as we implement these improvements and look forward to working with you to make the survey process as efficient and effective as possible.