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Increased oversight means more pressure on AOs to spot problems


December 1, 2018

Expect CMS to continue to put pressure on The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious fire safety and infection control issues the federal agency says they are still missing during surveys. 

Also, you may find CMS surveyors showing up soon with your AO team. But they won’t be there to watch you. They’re going to be watching the watchers, as a part of a pilot program that could potentially end the 60-day validation survey process.

In a new report to Congress, CMS says the disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, which includes fire safety violations.

Fiscal year 2016 began on October 1, 2015, and ended September 30, 2016, about a month before CMS began enforcing compliance with the 2012 editions of the NFPA 101 Life Safety Code® (LSC) and NFPA 99 Health Care Facilities Code on November 1, 2016. 

Both fire codes were adopted by CMS in June 2016 after more than a decade of requiring hospitals to adhere to the 2000 version of the LSC. Although long warned that the change was coming, many hospitals scrambled to play catch-up to the new requirements, as did AOs that had to update standards. 

Report required by Congress

CMS is required by regulation to evaluate how its approved AOs do their jobs and must report to Congress every year. After last year’s report was highly critical of AO performance, TJC and other AOs stepped up their efforts to find problems and are likely to do so again, say consultants.

In addition, the Senate Energy and Commerce committee earlier this year announced it was seeking answers from each of the hospital AOs about patient safety.

CMS evaluates AOs based on their ability to meet certain quality measures, including providing information back to CMS on problems found at hospitals in a timely fashion, and by conducting what it calls validation surveys in which CMS inspectors conduct a second survey within 60 days of an AO survey.

In those validation surveys, CMS state survey agency inspectors look for any problems in which a hospital fails to meet federal Conditions of Participation, which allows the facilities to bill Medicare. CMS assumes those condition-level problems were present during the AOs survey, and that is marked against the AO as a missed deficiency.

Consultants and others have noted that the practice of doing validation surveys as long as 60 days after an AO visit is unfair because the condition-level problem identified later might not have existed when AO teams were on site.

Double survey may be eliminated

On October 4, CMS announced several changes it says will make hospital patient safety and accountability more transparent for the public, including posting deficiency reports online for hospitals where it identifies condition-level problems.

In addition, CMS is launching a test project to directly observe AO surveyors on site as they work instead of conducting a follow-up validation survey within 60 days. 

“Direct observation will enable CMS not only to evaluate AO performance more effectively, but also to suggest improvements and address concerns with AOs immediately. This approach will relieve providers from having to undergo the burden of a state’s follow-up assessment,” said CMS, in announcing the pilot project.

“CMS will also analyze and incorporate State complaint investigations of accredited facilities as part of the agency’s strengthened validation program. This work will focus on identifying and monitoring accredited facilities that are out of compliance with Medicare health and safety requirements. CMS will use this information as an additional indicator of AO performance,” said the CMS announcement.

In the meantime, the validation surveys and disparities found continue to dominate the report to Congress.

CMS says it conducted 98 validation surveys in fiscal 2016, behind AO surveys at 3,448 hospitals. The top three condition-level deficiencies identified by CMS in fiscal 2016 were Physical Environment, Infection Control, and Governing Body.

LSC problems are typically cited under Physical Environment, with the top LSC problems identified with fire and smoke barriers, hazardous areas, sprinklers, and doors, according to the report to Congress. 


  • CMS memo QSO: 19-01-AO/CLIA, FY 2017 Report to Congress: Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program: https://tinyurl.com/CMS-AO-rpt2Congress-2017


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