CMS puts hospital surveys on limited hold as surge continues

by A.J. Plunkett (

CMS is putting a general hold on hospital surveys, except for those dealing with immediate jeopardy situations, for at least 30 days, in recognition of growing COVID-19 patient surges in many areas.

Hospitals facing recertification will be automatically extended for that 30 days.

Accreditation organizations are being asked to follow suit, although more information will be sent out later, said CMS.

In a memo to CMS state agencies, officials also asked hospitals and states where crises of care protocols were being implemented or even just considered to reach out to the federal agency for help.

Within the last few weeks, several states have said they were reaching crisis in their patient loads. Paramedics in Los Angeles were told at one point not to transport patients with a low likelihood of survival.

Regions in other states said they were considering implementing crisis of care standards allowing hospitals to determine who did or did not receive care. A hospital in Nevada last week declared a disaster.

According to memo QSO-21-13-Hospitals, agency officials said “CMS is aware that many states have Crisis Standards of Care protocols in place for hospitals that are experiencing extreme conditions due to patient surge, staffing shortages, or a lack of supplies and other resources. Hospitals that are contemplating or implementing crisis standards of care should notify their appropriate State Health Agency.”

“States that have hospitals in, or approaching, crisis standards of care are asked to contact their CMS Survey Operations Group location for information about additional flexibilities and assistance,” said the memo.

CMS officials said complaint investigations must and still will be carried out, but that to “ensure quality of care oversight, while providing hospitals the ability to focus on serving their patients and communities,” the federal agency is limiting the scope of hospital surveys for at least the next 30 days, with the potential for 30-day renewals to follow.

Hospital complaint surveys will be restricted to immediate jeopardy complaint allegations, and CMS will prioritize investigations based on:

  • Imminent danger to patients at the hospital.
  • Noncompliance with Medicare Hospital Conditions of Participation (CoPs) likely exists.
  • And if “immediate action must be taken to protect the health and safety of patients.”


“The investigation will be limited only to those CoP(s) necessary to ensure the health and safety of patients in imminent danger. CMS will only authorize and require investigation of the Infection Control CoP if the allegations support findings in this area. CMS will require Focused Infection Control surveys only for those complaints with allegations that support their inclusion.”

“While the circumstances above outline the priority expectations, CMS may authorize onsite investigations anytime, as determined appropriate by the CMS Survey Operations Group Location.”

In addition, hospital recertification surveys will be “suspended, except for a subset of hospital reaccreditation surveys, per additional guidance that will be forthcoming. Hospitals due to receive a recertification or reaccreditation survey will have their certification automatically extended for at least 30 days.”

“Additional guidance on Accrediting Organization reaccreditation surveys will be forthcoming. Accrediting Organizations will be directed (via separate notice) to similarly suspend reaccreditation surveys for 30 days and instead perform a targeted sample of reaccreditation surveys using a modified survey process in hospitals that meet defined parameters.”

“Hospital enforcement actions for deficiencies that do not represent immediate jeopardy will have their termination date extended for at least 30 days. while expected to continue to ensure safety and quality, hospitals will not need to submit a plan of correction nor will a revisit survey by the state survey agency (including desk review) be required,” said the memo.

Note that hospitals with an “uncorrected immediate jeopardy must demonstrate removal of the immediate jeopardy findings through an onsite survey. Once the immediate jeopardy has been removed, the above protocol will apply. Following this thirty (30) day period, or unless otherwise notified, hospitals will have up to 60-days to demonstrate compliance with any outstanding deficiencies. Further guidance will be issued outlining this process prior to the termination of this temporary survey prioritization.”

Look to the Accreditation & Quality Compliance Center for more information as it becomes available.