/ en Mon, 28 Apr 2025 04:59:14 -0500 Mon, 17 Mar 25 15:36:42 -0500 /news/headline/2025-03-17-survey-positivity-wanes-new-low-americans-mental-and-physical-health <p>Americans' assessments of their mental and physical health are the least positive they have been in the history of Gallup’s 24-year poll on the subject, with just 75% and 76% respectively rating their mental and physical health as “excellent” or “good,” according to its latest <a href="https://news.gallup.com/poll/658082/pandemic-effects-linger-americans-health-ratings.aspx" target="_blank">survey</a> released March 13. The results contrast from a record-high 89% mental health rating in 2012 and 82% physical health rating in 2003.</p> Mon, 17 Mar 2025 15:36:42 -0500 Standards, Surveys, Accreditation /news/headline/2024-04-12-aha-comments-proposed-rule-accrediting-organizations <p>Commenting April 12 on a proposed rule to strengthen oversight of accrediting organizations, AHA <a href="/lettercomment/2024-04-12-aha-comments-cms-proposal-accrediting-organization-oversight">told</a> the Centers for Medicare & Medicaid Services it supports requiring accrediting organizations to use Medicare’s Conditions of Participation and Conditions for Coverage as their minimum accreditation standards, and to provide an explicit crosswalk of their standards with relevant Medicare regulations. However, AHA recommended that CMS allow accrediting organizations to retain a limited number of “black-out” dates for accreditation surveys and provide same-day notice of the pending arrival of on-site surveyors. It also said CMS should transition to a direct observation approach for validation surveys; modify an “overly punitive” proposal to remove the deemed status of providers following certain validation surveys; clarify when the agency would make survey reports public; and eliminate duplicative complaint surveys.</p> Fri, 12 Apr 2024 14:51:43 -0500 Standards, Surveys, Accreditation <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Feb. 8 issued a <a href="https://public-inspection.federalregister.gov/2024-02137.pdf" target="_blank" title="DEPARTMENT OF HEALTH AND HUMAN SERVICES | Centers for Medicare & Medicaid Services | 42 CFR Parts 488 and 489">proposed rule</a> intended to strengthen its oversight of accrediting organizations (AOs) such as The Joint Commission and Det Norske Veritas (DNV). The proposed policies have implications for hospitals and health systems that rely on the AO accreditation process to demonstrate their compliance with Medicare’s Conditions of Participation (CoPs) and Conditions for Coverage (CfCs).</p><div><h2>Key Highlights</h2><p>Among other provisions, the proposed AO oversight rule would:</p><ul><li>Require AOs to use the specific language of CMS’ CoPs and CfCs as their minimum standards for accreditation.</li><li>Prohibit AOs from giving hospitals or other facilities advance notice of a survey.</li><li>Prohibit providers from using AOs to comply with CoPs and CfCs if they receive a condition-level citation during a validation survey until they demonstrate compliance directly to CMS.</li><li>Require AOs to provide CMS with all accreditation survey reports of the entities they accredit.</li><li>Prohibit AOs from providing paid consulting services within a year of an accreditation survey or in response to a complaint survey the AO conducts.</li><li>Require AOs to adopt specific conflict of interest policies for surveyors and other staff.</li></ul></div><h2>AHA TAKE</h2><p>AOs have a long-established role in allowing hospitals and health systems to demonstrate both their compliance with relevant Medicare requirements and their commitment to high quality, safe and equitable care. While accreditation is not required, most hospitals and health systems choose to work with AOs because their standards often exceed CMS’ and can evolve more nimbly to reflect changes in clinical practice. We appreciate that CMS’ expressed intent in this rule is to ensure AOs are conducting their work in a rigorous, consistent and unbiased manner. However, some of the proposals — including the restrictions on black-out dates and prohibiting providers from using accreditation to comply with Medicare regulations following some CMS validation surveys — are needlessly punitive to hospitals. We continue to review the proposed rule and will urge CMS to ensure its final policies strike an appropriate balance of strengthened oversight and flexibility.</p><h2>WHAT YOU CAN DO</h2><ul><li><strong>Share this Special Bulletin</strong> with your compliance, quality and safety and clinical leadership.</li><li><strong>Review the changes in the proposed rule</strong> to determine how they might affect your approach to working with AOs and meeting their requirements.</li><li>Consider <strong>submitting comments</strong> by the April 15 deadline.</li></ul><h2>SUMMARY OF KEY PROVISIONS</h2><p>CMS suggests its proposed changes to AO requirements would correct several perceived challenges. First, CMS believes that AO standards may not be sufficiently aligned with the agency’s CoPs and CfCs. In addition, CMS asserts that AOs sometimes fail to cite providers for being out of compliance with CoPs and CfCs when they should, pointing to “discrepancy rates” between AO surveys and CMS validation surveys. CMS also believes that AOs may not be conducting surveys on the “unannounced” basis that CMS intends. Lastly, CMS expresses concern about potential conflicts of interest between AOs and the organizations they accredit.</p><p>As a result of these concerns, CMS proposes a number of changes to how it conducts AO oversight. Several of the proposed changes would affect hospitals and health systems.</p><h3>CoPs and CfCs as Minimum Accreditation Requirements.</h3><p>AOs that meet CMS’ requirements have “deeming authority.” That is, AOs can deem accredited hospitals and other providers as compliant with CMS’ CoPs and CfCs if the AO’s standards are equivalent to or higher than CMS’. Hospitals that successfully complete accreditation from an approved AO are given “deemed status” by CMS.</p><p>To strengthen the alignment of AO standards with CMS requirements, CMS would require AOs to use the specific language of the CoPs and CfCs as their minimum accreditation requirements. While AOs would still be permitted to use standards exceeding Medicare’s CoPs, they would need to be explicit in their standards about which parts are specific to meeting CoPs. To that end, CMS proposes to require AOs to provide CMS with an explicit crosswalk of their standards and CoPs.</p><h3>Strengthened Definition of Unannounced Survey.</h3><p>Some AOs have permitted hospitals and other providers to identify a small number of black-out dates during which they could request AOs not conduct on-site surveys. In addition, some AOs have provided hospitals with a pre-arrival notification the day of an accreditation survey, usually no more than 60 minutes ahead. However, CMS believes that all AO surveys must be unannounced to more effectively assess whether organizations are in continual compliance with requirements. As a result, CMS proposes to prohibit the use of black-out dates and pre-arrival notifications. The agency also would require AOs to schedule surveys in ways that would not be predictable to hospitals or other providers.</p><h3>Validation Process Changes.</h3><p>Under current policy, CMS conducts validation surveys on a representative sample of hospitals and other providers each year. During validation surveys, state agency staff and sometimes CMS surveyors conduct a full review of the organization approximately 60 days after the organization completes accreditation. The survey is done “cold” — that is, the validation team does not actually see the AO’s survey report before it surveys the organization. Ostensibly, the goal of the validation process is to evaluate the performance of the AO. However, hospitals can and sometimes do receive citations during validation surveys.</p><p>In 2018, CMS also began piloting a direct observation model in which state agencies accompanied the AOs on their surveys to observe and evaluate what AOs did. CMS believes there is value to both types of validation surveys in assessing AO performance. As a result, CMS proposes to make a two-pronged validation survey process permanent. That is, CMS would conduct both “look back” surveys like what it does now, along with direct observation surveys like what it piloted in 2018.</p><p>In addition, CMS proposes that hospitals or providers receiving one or more condition-level citation on either type of validation survey could lose their deemed status. Condition-level citations are considered a higher severity citation by CMS. In addition, the provider could be subject to “ongoing review by the state survey agency…until [it] demonstrates compliance.” Organizations could regain their deemed status and ability to use an AO to demonstrate compliance with the CoPs once CMS finds the provider meets relevant requirements.</p><h3>CMS Collection of AO Survey Reports.</h3><p>Currently, CMS collects only high-level data from AOs (e.g., date of survey, overall findings, severity of problems, etc.) on their surveys. CMS asserts it has the authority to collect all reports from AOs and believes doing so would help it understand AO performance and identify discrepancies with state agencies. As a result, CMS proposes to require AOs to share all survey reports with CMS. CMS notes the law does not permit it to make AO reports on hospitals and other providers public unless it pertains to an enforcement action, such as terminating a provider agreement.</p><h3>AO Participation for Terminated Providers.</h3><p>CMS proposes to prohibit any providers that have had their Medicare provider agreement terminated from being deemed in compliance with CoPs and CfCs through an AO. Such providers could become eligible for deemed status through AOs if CMS judges them to be compliant with relevant CoPs and CfCs.</p><h3>AO Conflicts of Interest.</h3><p>CMS proposes limitations on when and whether AOs could provide paid consulting services to any of the providers it accredits. Specifically, AOs would be prohibited from providing consulting services within 12 months of the next scheduled AO survey and would be prohibited from providing consulting in response to a complaint received by the AO affecting that provider.</p><p>In addition, CMS proposes to require AOs to have conflict of interest policies and to collect disclosures from employees each year. Among other requirements, AO surveyors would be prohibited from surveying any facility where they worked in the previous two years, and AOs would be required to have policies ensuring surveyors do not have any involvement with the survey process or decisions of that facility.</p><h2>FURTHER QUESTIONS</h2><p>If you have further questions, please contact Akin Demehin, AHA senior director for quality and patient safety policy, at <a href="mailto:ademehin@aha.org">ademehin@aha.org</a>.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/02/cms-proposes-changes-to-requirements-for-accrediting-organizations-bullentin-02-15-2024.pdf" target="_blank" title="Download Special Bulletin: CMS Proposes Changes to Requirements for Accrediting Organizations"><img src="/sites/default/files/2024-02/cms-proposes-changes-to-requirements-for-accrediting-organizations-bullentin-02-15-2024.jpg" alt="CMS Proposes Changes to Requirements for Accrediting Organizations"></a></p></div></div></div> Thu, 15 Feb 2024 08:59:08 -0600 Standards, Surveys, Accreditation /news/headline/2023-07-21-joint-commission-further-streamlines-standards <p>Effective Aug. 27, the Joint Commission will eliminate or consolidate over 200 more accreditation <a href="https://www.jointcommission.org/standards/prepublication-standards/select-retired-and-revised-accreditation-requirements/" target="_blank">standards</a> in its hospital and other accreditation programs as part of an initiative to retire standards that go beyond the Medicare conditions of participation and don’t add value. <br />  <br /> “When we announced the first tranche of eliminated and revised standards in December 2022, hospital leadership and direct care providers alike were extremely supportive of the news that Joint Commission standards would be fewer but more meaningful,” <a href="https://www.jointcommission.org/resources/news-and-multimedia/news/2023/07/the-joint-commission-eliminates-additional-200-standards-across-all-accreditation-programs/" target="_blank">said</a> Jonathan Perlin, M.D., president and CEO of The Joint Commission Enterprise. “After such positive feedback, we are pleased to extend additional relief to our accredited organizations outside the hospital setting — especially as this is where patients most frequently receive care.” <br />  <br /> The commission eliminated 56 standards from its Hospital Accreditation Program effective this January as part of the <a href="/news/blog/2023-01-11-joint-commission-standards-review-fewer-more-meaningful-requirements" target="_blank">initiative</a> and plans to announce additional updates every six months.</p> Fri, 21 Jul 2023 14:13:47 -0500 Standards, Surveys, Accreditation /special-bulletin/2021-03-26-cms-lifts-suspension-hospital-survey-activities <p>The Centers for Medicare & Medicaid Services today <a href="https://www.cms.gov/files/document/qso-21-16-hospitals.pdf">announced</a> the immediate resumption of survey activities for all complaints.</p> <p>On Jan. 20, 2021, CMS issued guidance limiting hospital surveys for all complaints other than Immediate Jeopardy (IJ) complaints. The suspension period lasted for 30 days and was extended once, keeping the suspension in place through March 22, 2021.</p> <p>In the newly release guidance, CMS states that it is not extending the survey suspension beyond the March 22, 2021 date.</p> <p>A summary of the announcement follows.</p> <h2>SUMMARY OF SURVEY RESUMPTION GUIDANCE</h2> <p>As of March 23, 2021, survey activity may resume in accordance with the Non-Long Term Care Guidance found in <a href="https://www.cms.gov/files/document/qso-20-35-all.pdf">QSO 20-35-Al</a>l.</p> <p><em>Hospital Non-IJ Complaints</em>. Any non-IJ complaints received during the hospital survey suspension <strong>must be investigated within 45 days of the March 23, 2021 effective date</strong>.</p> <p><em>Hospital Plans of Correction</em>. As a byproduct of the survey suspension period, hospitals were permitted to delay Plan of Correction (POC) submissions until the suspension was lifted. Now that the suspension is no longer in place, providers <strong>must submit any delayed POCs within 10 days of March 23, 2021</strong> for any surveys that ended on or after Jan. 20, 2021.</p> <p><em><strong>NOTE:</strong> If your hospital or health care system is still experiencing a COVID-19 surge that will make the development and implementation of a POC difficult, you should contact your state agency or CMS location to request an extension.</em></p> <p><em>Hospital Desk Reviews</em>. State surveyors are permitted to perform desk reviews of all open surveys that cited any level of noncompliance, including IJ complaints in which the IJ finding was removed or moved to a lower level of non-compliance. This applies only to outstanding enforcement actions held during the survey suspension. In instances in which an IJ finding existed and was not removed, surveyors are required to conduct an onsite revisit.</p> <p><em>Hospital Revisit Surveys</em>. All onsite revisits are authorized and should resume. Further, in order to perform a desk review, state agencies must request that facilities submit evidence supporting correction of noncompliance, which can include evidence of training, staff attendance and staff competency evaluations. In those instances where a desk review is performed, state agencies will have discretion to include the specific clinical area of concern in the next onsite survey.</p> <p><em>Open Hospital Enforcement Activities</em>. Hospitals with open enforcement actions not constituting IJ will have at least 60 days, and up to 90, to demonstrate compliance with any outstanding non-IJ deficiencies.</p> <h2>NEXT STEPS</h2> <ul> <li>Please share this document with your leadership team, as well as quality and patient safety personnel.</li> <li>If your organization is unable to develop and implement a POC due to a COVID-19 surge, please notify Nancy Foster (<a href="mailto:nfoster@aha.org">nfoster@aha.org</a>) or Mark Howell (<a href="mailto:mhowell@aha.org">mhowell@aha.org</a>), as well as your state agency and/or CMS location.</li> </ul> <h2>FURTHER QUESTIONS</h2> <p>If you have questions, please contact AHA at 800-424-4301.</p> Fri, 26 Mar 2021 16:22:02 -0500 Standards, Surveys, Accreditation /letter/2018-11-19-letter-proposed-rule-reducing-burden-conditions-participation <h4><a href="/system/files/2018-11/181119-letter-reg-burden-cops.pdf">Download the letter (PDF) below</a></h4> <hr /> <p><em>Re: CMS—3346—P, Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Proposed Rule (Vol. 83, No. 183), Sept. 20, 2018.</em></p> <p>The AHA supports the proposals to allow health care systems to opt to take a system-wide approach to Quality Assurance and Performance Improvement and Infection Control with oversight from the system governing board; change current Medicare reapproval requirements for transplant centers; and change the frequency and nature of emergency preparedness testing requirements for hospitals.</p> <p>However, we strongly oppose the removal of the requirement that ASCs have a written agreement or physician admission privileges with hospitals. Further, we have some concerns with the proposed elimination of current preoperative medical history and physical examination requirements in lieu of ASCs and hospitals establishing their own requirements.</p> Mon, 19 Nov 2018 10:49:13 -0600 Standards, Surveys, Accreditation /news/headline/2018-08-17-cms-grants-continued-approval-hospital-accrediting-organization <p>The Centers for Medicare & Medicaid Services has <a href="https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-17815.pdf">approved</a> DNV GL – Healthcare for continued recognition as a national accrediting organization for hospitals that wish to participate in the Medicare and Medicaid programs. The decision is effective for four years.<br />  </p> Fri, 17 Aug 2018 14:50:52 -0500 Standards, Surveys, Accreditation Tue, 14 Aug 2018 11:07:26 -0500 Standards, Surveys, Accreditation /news/headline/2018-03-13-ec-chairmen-seek-information-cms-oversight-hospital-accreditors <p>Republican leaders of the House Energy & Commerce Committee last week <a href="https://energycommerce.house.gov/news/press-release/ec-leaders-request-information-hospital-accreditation-processes/">asked</a> the Centers for Medicare & Medicaid Services and four hospital accrediting organizations to provide certain information about the hospital survey process and CMS oversight of the organizations by March 23. “Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’s oversight as well as the rigor of the AO survey process,” <a href="https://energycommerce.house.gov/news/letters-cms-four-hospital-accreditation-entities/">wrote</a> Committee Chairman Greg Walden (R-OR), Health Subcommittee Chairman Michael Burgess (R-TX), and Oversight and Investigations Subcommittee Chairman Gregg Harper (R-MS). The chairmen also asked the four accreditors – The Joint Commission, Center for Improvement in Healthcare Quality, Bureau of Healthcare Facilities Accreditation, and DNV GL Healthcare – to brief their staff on their survey processes and interactions with CMS by April 6. </p> Tue, 13 Mar 2018 15:03:02 -0500 Standards, Surveys, Accreditation /news/headline/2017-12-01-hhs-announces-pilot-project-optimizing-administrative-simplification <p>The Department of Health and Human Services is seeking health plan and clearinghouse volunteers to participate in an HHS Health Insurance Portability and Accountability Act administrative simplification optimization project pilot. Volunteers will undergo reviews of their transactions for compliance with adopted standards, code sets, unique identifiers and operating rules. Reviews will be conducted beginning January 2018. For those interested in volunteering for the project, contact <a href="mailto:HIPAAcomplaint@cms.hhs.gov" target="_blank" data-fontcolor="1">HIPAAcomplaint@cms.hhs.gov</a>. U.S. health care providers could save more than $7.9 billion annually and at least 1.1 million labor hours per week if commercial health plans fully adopted the seven national standards for electronic business transactions, according to the latest annual <a href="https://na01.safelinks.protection.outlook.com/?url=http:%2F%2Fsend.aha.org%2Flink.cfm%3Fr%3Ds0GKwMNNI8St-dolT7m-JQ~~%26pe%3DnALeOD8_LBaGd5PRP3s-jd3hrd5tfUqRYbBzmCRrgt7QICigoUoUJAuDEyjXTq-XA046RpdampA93MmEP17erg~~%26t%3Dcc15C2olyKB_fPUTztp53Q~~&data=02%7C01%7Csdean%40aha.org%7C5de535808ad04766c83808d538f9baad%7Cb9119340beb74e5e84b23cc18f7b36a6%7C0%7C0%7C636477567591278841&sdata=9NSMhVgsvwyN2M9F3WkaG%2BN%2F91FQNs16%2ByyXSpmUBcA%3D&reserved=0" target="_blank" data-fontcolor="1">CAQH Index</a>. Health plans could save an estimated $1.4 billion annually if the standards were fully adopted, the report adds.</p> Fri, 01 Dec 2017 11:53:00 -0600 Standards, Surveys, Accreditation