CMS Releases Hospital Survey Priorities

January 28, 2021

The Centers for Medicare & Medicaid Services (CMS) has issued updated guidance regarding hospital survey limitations that, according to CMS, are to ensure quality of care oversight while providing hospitals the ability to focus on serving their patients and communities. In a memo to State Survey Agency Directors, CMS outlined the following limitations that will be in effect for 30 days, beginning on Jan. 20 (with the potential for 30-day renewals with additional notice):
  • Hospital complaint surveys will be restricted to Immediate Jeopardy complaint allegations with CMS prioritizing onsite complaint investigations based on imminent danger to the patient, likelihood of noncompliance with the Medicare Conditions of Participation, and whether immediate action must be taken to protect the health and safety of patients. CMS, however, notes that it may authorize investigations anytime, as determined appropriate by the CMS Survey Operations Group Location.
  • Hospital recertification surveys will be suspended except for a subset of hospital reaccreditation surveys. Accrediting organizations will be directed to suspend reaccreditation surveys for 30 days and should expect to receive guidance with additional information about a modified reaccreditation survey process.
  • Hospital enforcement actions for deficiencies that do not represent immediate jeopardy will have their termination date extended for at least 30 days to remain consistent with the survey guidance. During this time, hospitals will be expected to continue to ensure safety and quality but will not be required to submit a plan of correction and will not receive a revisit survey. Hospitals that have an uncorrected incident of Immediate Jeopardy must demonstrate removal of the Immediate Jeopardy findings through an onsite survey. CMS wrote that hospitals can expect additional guidance on enforcement.
A copy of the CMS memo is available here.

This story originally appeared in the January 28, 2021 edition of WHA Newsletter