Mac’s Safety Space: CMS survey warning—There will be no warning!

By Steve MacArthur, Hospital Safety Consultant

In its ever-increasing strategies to assert control over the accreditation survey process, the good folks at CMS have basically instructed the various accreditation organizations to cease and desist from any practices that might reflect an early warning of a survey visit.

This desire on the part of CMS has been in play for well more than a decade (2009 would be the year this “shoe” first dropped—you can read the details here). At the time, the instructions were aimed at state agencies, with the intent being (with some minimal exceptions) that accreditation visits, complaint surveys, re-surveys, etc. would all be completely unannounced (conjure up your own images of surveyors parachuting out of stealth helicopters). Not a nod, not a whisper—nothing in the way of notification.

Certainly, back in the immediately post-9/11 days there was a fair amount of angst regarding the identification and management of any “impostor” surveyors that might be attempting to gain access to security-sensitive areas in hospitals or other nefariously related activities, which I think we can all agree was a legitimate threat potential. Subsequent, it became the practice of some accreditors to post surveyor information on client-access web portals on the day of survey to allow for identification of the “real deal.” Thus was born the practice of the survey coordinator for each organization to be visiting said web portals every morning to see if there was any indication that today was “game day.”

But all that is going away, effective pretty soon (the various accreditation organizations had until July 14, 2023, to inform CMS as to the process changes being made to ensure compliance).

What is also going away is the use of “blackout dates” in which organizations could rule out certain days or weeks from the survey schedule—CMS is having none of that (so to speak). At the very least, this is going to change a lot of folks’ definitions of what “survey ready” actually means, from a practical/operational standpoint.

There’s been some indication this year that there’s some work that’s been done to more definitively randomize the scheduling of surveys. At the end of the day, I don’t know that this is necessarily going to change the level of survey vulnerability at any given time (unless you want to consider the vulnerabilities relating to panic), at least as far as the physical environment is concerned.

Folks need to carefully manage the data collected during environmental rounding and other activities in which work orders might be generated in order to implement a “day of” response protocol that reflects the conditions that are most likely to be encountered. There will always be the potential for the “one off” findings—you really need to focus your resources on the “clear and present” vulnerabilities that are part of everyday life in healthcare. I would encourage you to look back at the last two (and maybe three) accreditation surveys and ask yourself: “Would I be surprised to find this condition/practice today?”

Truly, the function of sustainability is not so much preventative (though there can be an element of that) as it is a function of identifying things that need to be done and “getting them in the queue.” There will almost certainly be FIFI (find it, fix it) items—hopefully those are occurring without your having to implement a formal process. It’s the stuff that requires additional effort, time, resources that need to be the focus.

Again, your past survey reports (and yes, I know that the past is no indicator for the future; the past is also tense—but nothing like the present when there is no survey early warning signal) will help you “remember” where you’ve stubbed your (metaphorical) toe in the past. Make sure your process is more like a pair of steel-toed work boots than a pair of sandals.

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

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CMS, Environment and Facilities