2020 Report to Congress: CMS Remains Critical of AO Performance

By A.J. Plunkett

Missed deficiencies within the physical environment, fire safety, infection control, and patients’ rights continues to dominate CMS’ annual report card on the annual performance of accrediting organizations (AO).

In a report to Congress released late Wednesday, CMS said it will continue putting pressure on AOs to do a better job of enforcing Medicare’s Conditions of Participation but is also fine-tuning the process of how it validates their performance.

Concerns remained concentrated on AOs failures to find problems within the physical environment that were spotted by CMS’s state survey agencies (SA) during surveys to validate the AOs findings. Validation surveys are supposed to be conducted within 60 days of an AO’s triennial visit.

“Examining the specific condition-level deficiencies cited by the SAs across all 60-day validation surveys provides an indication of the types of quality problems that exist in these facility types as well as the relationship between SA and AO citations for specific conditions,” wrote CMS in the report.

“CMS uses two approaches for this analysis: (1) a review of the types of condition-level citations identified by SAs and the comparable AO deficiency findings; and (2) a comparison of the number of surveys with PE condition-level deficiencies and the number of surveys with other types of condition-level deficiencies. Both approaches highlight the same conclusion: SAs identify more PE condition-level deficiencies than any other type of deficiency on validation surveys; and AOs miss a significant number of these PE deficiencies.”

While the report is dated fiscal 2020, the AOs were evaluated during federal fiscal year 2019, which would have gone from October 1, 2018, through September 30, 2019 — before the COVID-19 pandemic upended both CMS and AO surveys.

CMS has increased pressure on AOs as well as hospitals for a few years, including creating a website to highlight the CMS surveys that revealed the most serious patient safety deficiencies and separating them by the AO responsible for oversight.

In just more than a decade, the number of complaint surveys CMS has investigated in hospitals has gone from 1,294 in 2008 to 3,491 complaint surveys in 2019.

The Joint Commission continues to be the largest of the AOs, with responsibility for 2,891 hospital surveys in fiscal 2019, compared to the next largest AO, DNV Healthcare, at 286, according to the report.

The oldest CMS-approved hospital accreditation program in the nation, the Healthcare Facilities Accreditation Program (HFAP) surveyed 89 hospitals in fiscal 2019, while the Center for Improvement in Healthcare Quality (CIHQ) did just 68 surveys.

The pressure to improve performance was largely behind CMS’ move in July 2020 to limit The Joint Commission to just a two-year approval, and to HFAP’s merger with the Accreditation Commission for Health Care (ACHC) that October. HFAP is now transitioning its new brand name as ACHC.

TJC has already submitted its application for renewal as an AO. CMS published a request for comment on the application on December 10 in the Federal Register. Comments will be accepted through January 9. See the Federal Register announcement for details on how to submit comment.

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.