CMS restarting pilot project putting agency surveyors side-by-side with AO teams

by A.J. Plunkett (

Surveyors from CMS could start appearing along with survey teams from each accrediting organization (AO) as the federal agency resumes its full AO validation survey program.

All non-emergent validation surveys were suspended when the COVID-19 pandemic shut down almost all surveys nationwide.

CMS officials said in its most recent report to Congress, "Fiscal Year 2021, Review Of Medicare’s Program For Oversight Of Accrediting Organizations And The Clinical Laboratory Improvement Validation Program,” that it was resuming its full validation survey program, including a pilot project in which CMS and AO survey teams were on site at the same time.

The report was released May 10 as a CMS Quality, Safety & Oversight group memo, QSO-23-14-AO/CLIA, and covers surveys conducted during the fiscal year 2020, from October 1, 2019, to September 30, 2020.

The project validation program had garnered good reviews, but had been suspended in August 2019 for a redesign, according to CMS.

For years, hospital compliance managers faced the dread of possibly facing back-to-back surveys as CMS used what it calls validation surveys to check behind AO surveyors as part of the annual performance review required by Congress.

Those CMS validation surveys were required within 60 days of the AO survey but often happened within only a couple of weeks or sometimes days, drawing the ire of beleaguered compliance managers. Meanwhile, the surveys were criticized by AOs that argued deficiencies found during the CMS visit might not have existed when their own surveyors were onsite.

In 2018, CMS launched the pilot project in which CMS teams would work alongside AO teams not only evaluating the particular AO’s survey process, but noting when problems were missed and noting especially when the missed problem rose, in CMS’ estimation, to a condition-level finding.

According to the AO report, the pilot project is scheduled to restart in fiscal 2023, which began October 1, 2022.

Otherwise, the report to Congress shows that CMS is still finding a number of disparities between the problems CMS surveyors find and those found by the AO survey team in the days or weeks before, based on 60-day validation surveys that were able to be conducted in the truncated fiscal 2020.

Just as it has in years past, CMS told Congress it wants the AOs to step up survey performance in the main compliance problems, particularly involving fire safety and physical environment standards.

Four AOs are approved by CMS to accredit hospitals: The Joint Commission, the Accreditation Commission for Health Care (which formerly included hospitals accredited by HFAP), Center for Improvement in Healthcare (CIHQ), and DNV Healthcare.

For more on how each AO performed and the areas CMS wants them to concentrate on in future surveys, see the June issues of Inside Accreditation & Quality and Healthcare Safety Leader.



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