Mac’s Safety Space: Better late than never—CMS is still keeping score!

By Steve MacArthur, Hospital Safety Consultant

In years past, the term-ending grades for the various accreditation organizations have been transmitted to Congress in the late fall/early winter (the winter portion depends on where you are), but for Fiscal Year ’21 (Oct. 1, 2019 – Sept. 30, 2020), CMS delayed publication until May 2023.

There’s no clear indication in the publication that speaks to the change in “drop date,” though I suppose it’s possible that managing the survey data with everything else going on in the world may have had an impact, so I guess we’ll have to wait and see if Spring is going to be the new time for delivery of the report cards (I don’t think it was ever a really fun holiday present, so here’s hoping).

As a somewhat related aside before we get too much further into this, if you’re interested in seeing how many accreditation organizations there are, you can download the full report at the link above and turn to page 12. There you’ll find the list of accreditors as well as what types of CMS-approved survey programs are available from each. I suspect that, given the fabulous experiences in survey year 2023, there might be some folks who elect to do a little shopping around. Whether or not they change accreditors is the unknown, but I do think the pendulum operated by our friends in Chicago are way over in the “I’d rather have a colonoscopy or dental work” range.

As to the results outlined in the report, it is very clear that the focus on the physical environment is not going away any time soon (is there anyone out there that thought it might? I didn’t think so…), with the greater share of disparities being associated with the conditions and standards relating to the physical environment than those relating to patient health and safety.

What’s interesting to me—and it’s not really clear to me how, or even if, this is occurring—is whether there are physical environment elements that are impacting the patient health and safety findings. The scenario I have in my mind’s eye is the identification of self-harm risks in the environment that might be cited under the Patient Rights Condition of Participation (specifically, a patient’s right to a safe environment, Tag A-0144, §482.13(c)(2) - the patient has the right to receive care in a safe setting.) In looking at the graphs for psychiatric hospitals, it’s the Patient Rights condition that sits at the top of the heap (the data source is complaint surveys as opposed to validation surveys), so environmental conditions may be in the mix, but that particular devil appears not to be in the details.

The report does, however, provide a little bit of a breakdown for the Life Safety Code®-related findings and they are as follows:

  • Sprinkler – No surprise that this would be the most frequently cited area. So many things can go sideways from sprinkler heads with foreign materials to 18-inch storage to missing escutcheons, all you really need to do is look
  • Means of egress – I guess this will tend to be a perennial. Hard to say what’s driving the numbers, but (as with sprinklers) lots of things can go wrong
  • Electrical – I would love more detail on this; my “gut” makes me think that relocatable power taps are in the mix for this, but there could also be a smattering of medical equipment findings
  • Doors – If you have a facility of any magnitude and have people working within that facility, they’re going to beat up doors, wedge doors, hang stuff they shouldn’t on doors – another seemingly endless list of possibilities
  • Fire alarm – This could be documentation issues; could be issues with the integrity of the ceiling membrane; might even be obstructed access to pull stations

Somewhere back in the mists of time, there was an indication (right around the time that CMS adopted the 2012 edition of the Life Safety Code) that they would be making training available to folks to get them up to speed with the changes. For some reason, I completely forgot about that (perhaps assuming that it would never quite reach fruition) and when I noticed a passage in the FY 2021 report, I found it again and was prompted to do a web search. And what to my wondering eyes should appear, but a fully laid out introductory course in which we all may partake. I have no idea how useful it is (I’m going to do a dive on it one of these days – if it’s worth it, I’ll surely let you know), but if you’re feeling adventurous…

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at