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TJC, other AOs told to step up on finding EoC, LSC violations


November 10, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

Expect CMS to continue its crackdown on The Joint Commission (TJC), HFAP, and other accrediting organizations (AO) for fire safety and physical environment oversight. In its latest report to Congress on AO performance, CMS said accreditors continue to miss too many condition-level deficiencies during surveys, particularly in those areas.

CMS is recommending that the main way for AOs to improve their performance is to focus on the top conditions that each organization repeatedly misses—which for hospitals are almost entirely within the environment of care (EoC) or the Life Safety Code? (LSC).

The good news is that CMS has already launched its pilot program to begin conducting validation surveys to assess performance at the same time AO surveyors are on site. The effort is designed to eliminate the time, money, and stress hospitals have endured with back-to-back accreditation visits.

For years, CMS has conducted the validation surveys by showing up at hospitals within 60 days of a renewal accreditation survey. Critics have long said that practice is problematic since deficiencies apparent to CMS surveyors may not have existed when AO surveyors were on-site in the weeks or months before (IJC 10/15/18).

The pilot program and the continuing concerns over fire safety and other serious oversights by AOs are part of CMS’ fiscal year 2018 report to Congress on how the agency oversees accreditation of the nation’s hospitals and other healthcare organizations who have to meet Conditions of Participation (CoP) or Conditions of Coverage (CfC) in order to bill Medicare.

Report to Congress online

The 108-page “Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program, Fiscal 2018” was published online in August.

The report covers AO performance for fiscal year (FY) 2017, which ran from October 1, 2016, through September 30, 2017.

During that time, there were 3,567 hospitals that chose to be deemed eligible to bill Medicare through one of four approved AOs, rather than survey from a CMS state survey agency (SA). Of those hospitals, 27 faced initial surveys from an AO and 1,268 faced renewal surveys. Overall 15 hospitals were denied accreditation, while 98 chose to withdraw from using an AO and switched to CMS SA authority.

The report focuses on how well the AOs met certain performance measures, such as timely notification to CMS of a denial of accreditation, and the disparity rates between condition-level deficiencies identified by an AO and those found by CMS in a 60-day validation survey.

The four AOs approved by CMS to conduct accreditation surveys for hospitals are TJC, the Healthcare Facilities Accreditation Program (HFAP), the Center for Improvement in Healthcare Quality (CIHQ), and DNV GL-Healthcare (DNV).

TJC and HFAP have been accrediting hospitals for Medicare billing since the government health insurance program for retirees was created in the 1960s. DNV entered the arena in 2008 and CIHQ in 2013.
TJC dominates the field, accrediting 3,104 or 87% of hospitals in FY 2017. DNV was the AO for 308 hospitals, HFAP for 113, and CIHQ for 42 facilities.

AOs face scrutiny

Each AO must regularly submit its standards and survey policies and procedures for approval by CMS and make changes as the agency sees fit, which recently has included a widening of requirements on ligature risk and suicide prevention.

CMS has also overseen several changes related to the 2016 implementation of the use of the NFPA 101-2012 Life Safety Code and NFPA 99-2012 Health Care Facilities Code, updating fire safety requirements that by then were well over a decade out of date. (Previously, CMS held hospitals to the 2000 LSC.)

During FY 2017, CMS conducted 95 validation surveys at hospitals and found conditions it said was missed by the AO in 45 surveys, for a disparity rate of 45.26%.

The top CoP deficiency was in Physical Environment, which includes all Life Safety deficiencies and many of the ligature or self-harm risk deficiencies, with a 30.5% disparity rate from those identified by the AO. The other top CoP deficiencies missed were:

  • Governing Body, 13.7% disparity rate
  • Infection Control, 11.6%
  • Quality Assurance and Performance Improvement (QAPI), 9.5%
  • Food and Dietetic Services, 5.3%
  • Patient Rights, 5.3%

The top 10 missed citations under the LSC were, in order, means of egress, fire and smoke barriers, sprinkler systems, electrical systems, fire doors, hazardous areas, flammable and combustible storage, fire alarms, construction fire safety, and fire extinguishers.

How did each of the AOs perform? That’s a tough question to answer, given that two of the four AOs—HFAP and CIHQ—faced so few validation surveys. CMS only got to 3% of the hospitals that faced an AO survey in FY 2017, which it blamed in part on decreased funding.

In addition, the report noted more than once that the disparity rates, as calculated according to regulation, had limitations in assessing performance of the individual AOs. CMS also assessed each AO according to how the AO met several of its own performance measures, including such things as timely notification of denial of accreditation to CMS and including all the necessary information in its notification letters.

CMS wrote that it historically has provided AOs with disparity rate analyses and opportunities for discussion on disparity rates across all CMS-approved accreditation programs, but the rates have stagnated over time, particularly with Physical Environment and LSC deficiencies.

“While CMS continues to utilize this strategy as an attempt to effect a positive change in disparity rates, CMS has determined that additional interventions are required,” wrote CMS officials, who added that they have undertaken “a number of additional strategies to address this issue. In March 2017, CMS implemented monthly AO Liaison calls during which a number of topics are discussed, including disparity rate findings and possible solutions, as well as overall AO performance in other areas.”

Officials also noted that “CMS has also participated in AO surveyor training sessions, delivering analysis findings directly to the AO’s survey cadre. And finally, CMS is embarking upon a Validation Program process improvement project, where the entire Validation Program will be evaluated for effectiveness and comparability.”

Redesign of validation survey process underway

CMS says it appointed a workgroup to redesign the validation survey process in March 2018. The overall goal of the project is to have facilities “surveyed simultaneously by the appropriate SA and the AO, using the same Medicare certification full survey process” according to whether the facility is under Medicare CoPs or CfCs.

“Using the CMS/AO Observation Worksheet and Rating Guide developed by CMS, the SA surveyor team will evaluate the skill, knowledge, and performance of the AO’s survey process and score the AO accordingly. There will be no separate SA validation survey conducted,” CMS noted.

The SA surveyors will complete the observation worksheet and what CMS called an “abbreviated 2567” after the survey was completed.

In turn, the AO will provide its survey report with a plan of correction going to the CMS regional office. The data from the CMS/AO Observation Worksheet will be used for the disparity data report going forward, said CMS.

In a blog posting at the end of August, Mark G. Pelletier, RN, MS, the chief operating officer, Accreditation and Certification Operations, and chief nursing executive for TJC said the commission had collaborated with CMS on redesigning the process.

“Pilot surveys have been conducted nationally across multiple Medicare providers and suppliers with the state survey team functioning in an observation role during the accreditation survey event. Although The Joint Commission and the state agencies have different processes and methods for conducting a survey, pilot surveys showed the teams arrived at the same conclusion relative to survey findings and overall survey outcome,” said Pelletier. “Organizations selected for the live pilot surveys expressed appreciation for eliminating the separate state survey.”

Pelletier said CMS has indicated that the pilot program will continue through at least September 30, 2020, “and will be used to supplement the existing validation survey process until CMS is able to update the regulatory language within 42 CFR 488,” the section of regulation that authorizes how validation surveys are conducted.

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