Credentialing & Privileging | 02.24.21
CMS Updates Accrediting Organizations on New Survey Processes
On January 20, 2021, CMS’s Quality, Safety & Oversight Group announced that the due to the recent COVID-19 patient surge, the Agency would place a hold on hospital surveys for a minimum of 30 days, except for those needed in emergencies. At that time, CMS informed Accrediting Organizations (AOs) about these holds and stated that they would follow up with more information later.
CMS directed AOs to contact their AO liaisons at CMS if a hospital is scheduled to undergo its three-year survey during a COVID-19 patient surge. CMS’ now issues color-coded guidance from county data to determine whether a facility can resume surveys. If a facility is located in a county with a high positivity rate, CMS will code that facility as red (severe) and make it a low priority for surveying.
CMS then sent a letter to AOs on February 1, 2021 issuing a hold on most routine reaccreditation surveys through February 19, 2021. CMS may extend the hold in 30-day increments throughout the public health emergency (PHE). CMS also provided AOs the option to use a “Hospital Focused Modified Reaccreditation Survey Model (HFMS).” If an AO uses this model, it will receive a list of facilities due for reaccreditation that will receive an HFMS survey, regardless of county-level positivity rate. CMS uses the following criteria to place hospitals on this list:
- “Complaints received by the AO (or immediate jeopardy occurrences) during the PHE related to infection control and patient safety;
- Media reports regarding health and safety concerns during the PHE; or
- OSHA violations during the PHE.”
The HFMS model limits activities such as document review, staff/leadership interviews, medical record review, and performs many of these activities remotely to reduce the number of surveyors/days on-site at a facility. An AO will need to seek CMS-approval based on specific policies and procedures to utilize an HFMS. This model is different from the previous CMS models that required AOs to conduct a second on-site survey once the PHE ends. Under HFMS, AOs will not need to conduct a follow-up survey and CMS will accept the survey as presented.
CMS likely created the HFMS model in response to AO requests for more flexibility in conducting surveys and avoiding lengthy process.
View the Health Leaders Media analysis article for more information. Stay connected to NAMSS by visiting the NAMSS COVID-19 Resources Page and Gateway.