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CMS examines possible Conflicts of Interests in Accreditation Organizations

By John Commons 

Federal regulators are asking for public comment and cite ‘disparity rates’ between state audits and AO reviews of healthcare facilities.

The Centers for Medicare & Medicaid Services is asking questions about potential conflicts of interest between Medicare accrediting organizations and the healthcare facilities they monitor.

“We are concerned that the practice of offering both accrediting and consulting services–and the financial relationships involved in this work–may undermine the integrity of accrediting organizations and erode the public’s trust,” CMS Administrator Seema Verma said in a media release.

“Our data shows that state-level audits of healthcare facilities are uncovering serious issues that AOs have missed, leading to high ‘disparity rates’ between the two reviews,” Verma said.

“We are taking action across-the-board to ensure the quality and safety of patient care through strengthened CMS oversight of AOs, and today’s RFI is a critical component of that effort.”

The query likely will include an examination of The Joint Commission, the nation’s largest hospital accrediting organization. In a media statement, The Joint Commission said it is reviewing CMS’s requests for comment, but said it is confident in the integrity of the “firewall” between its consulting and accrediting divisions.

“The Joint Commission recognizes the importance of assuring the integrity of the accreditation process, which we accomplish by prohibiting any sharing of information about consulting services for individual organizations with anyone involved in accreditation,” the statement read.

“The Joint Commission as an accrediting organization and Joint Commission Resources, Inc. as a provider of education and consulting services are two separate organizations. The Joint Commission enterprise has long-standing firewall policies, practices and procedures in place that assure that this goal is achieved,” the statement read.

CMS Extends Time to Finalize Discharge Planning Proposal

By AJ Plunkett

If you were expecting to implement the latest discharge planning revisions to the Medicare Conditions of Participation soon, you can breathe a little easier for now. CMS took the unusual step on October 30 of announcing a year’s time extension to publish the final rule. The extension runs through November 3, 2019.

By federal regulation, such rules must be finalized and published with three years of proposal “except under exceptional circumstances.” In announcing the time extension for the final rule, which could have significant impact on hospitals and home health agencies, CMS noted that it received 229 comments after it first proposed the rule November 3, 2015.

“In this case, the complexity of the rule and scope of public comments warrants the extension of the timeline for publication,” according to the Federal Register notice published online October 30.

The rule, “Medicare and Medicaid Program; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies,” has been under review by CMS’ legal team since at least April, according to consultants and other officials.

CMS wants to coordinate with IT

CMS indicated that part of the delay was in order to collaborate with HHS’ Office of the National Coordinator for Health Information Technology.

Among other things, CMS is proposing to “implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185), that requires hospitals, including, but not limited to, short-term acute care hospitals, CAHs and certain post-acute care (PAC) providers, including long term care hospitals, inpatient rehabilitation facilities, HHAs, and skilled nursing facilities, to take into account quality measures and resource use measures to assist patients and their families during the discharge planning process in order to encourage patients and their families to become active participants in the planning of their transition to the PAC setting (or between PAC settings),” according to the extension announcement.

Based on information received from the public and other stakeholders, CMS says it needs more time to evaluate the impact of the proposed rule.

“The commenters presented procedural and cost information related to their specific circumstances, and the information presented requires additional analysis,” says CMS, adding that “we have determined that there are significant policy issues that need to be resolved in order to address all of the issues raised by public comments to the proposed rule and to ensure appropriate coordination with other government agencies.”

CMS Report: AOs missing fire safety and IC deficiencies during survey

Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious life safety, environment of care, and infection control issues the federal agency says they are still missing during surveys.

In the newest report to Congress assessing AO performance, CMS says the overall disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, says the report. CMS is particularly concerned that AOs are missing key Life Safety Code® (LSC) deficiencies, with fire and smoke barriers, sprinkler systems, electrical systems, hazardous areas, and means of egress taking the top five categories for missed problems in fire safety at hospitals.

Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 LSC, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.

This is on top of TJC’s response to criticism in the report released last year. TJC began pushing its own surveyors to cite every life safety deficiency, no matter how small, Allen says.

More on this topic can be found on

CMS Revises Memo on Requirements to Reduce Risk of Legionella Infection

Be prepared for renewed interest in your water management program and especially how it is designed to prevent the spread of Legionella infection. CMS just updated its memo from last year on requirements to reduce the risk of Legionnaire’s disease, in part to clarify expectations for hospitals and nursing homes (NH).

While there are no new expectations for hospitals or critical access hospitals (CAH), be aware it does add a specific statement that “facilities must have water management plans” as well as a new note that testing for waterborne pathogens is left “to the discretion of the provider,” according to the letter to CMS’ Quality, Safety and Oversight (QSO) group, formerly the Survey & Certification (S&C) group.

“The terms ‘plans’ and ‘policies’ are sometimes confusing to hospitals,” warns Kurt Patton, the former director of accreditation services for The Joint Commission (TJC) and founder of Patton Healthcare Consulting, now in Naperville, Ill.

“TJC already requires a utilities management plan and water is a component of that. The unknown will be if CMS surveyors say they don’t want to look at a utilities plan, they want to look at a water management plan,” explains Patton. “At a minimum, I would suggest accredited hospitals have a table of contents and a subject header for ‘Water Management Plan’ inside their overall utilities plan.”

The memo, QSO 17-30-Hospitals/CAHs/NHs, was published July 6 and supersedes the former S&C 17-30-Hospitals/CAHs/NHs, issued in June 2017, and it adds more specific expectations for long-term care (LTC) facilities. [more]

New CMS guidance on ligature risk says Joint Commission recommendations set the bar

Expect CMS surveyors to be referring to recommendations set out by The Joint Commission last fall when looking for ligature risk and other environmental hazards in the push to make hospitals and psychiatric units safer for patients at-risk of self-harm.

For now, assess your hospital’s environmental compliance against those Joint Commission recommendations, regardless of what organization you might use for accreditation, and be prepared to provide one-to-one observation of at-risk patients if you cannot provide a ligature-resistant environment, says one safety consultant.

In a new memo to its state survey agencies, CMS said it would use those Joint Commission recommendations — drawn from a task force convened by the accreditor that included several CMS experts in suicide prevention — as the federal agency goes forward with clarifying and updating interpretive guidelines for its surveyors.

The memo QSO: 18-21-All Hospitals, “CMS clarification of Psychiatric Environmental Risks,” from the Quality, Safety & Oversight Group (QSO), formerly known as the Survey and Certification Group, is dated July 20, although it was not posted online until Aug. 1.

CMS says Joint Commission panel good enough

In earlier communications, CMS had indicated it would convene its own group of experts to update its guidance to increase focus on ligature as well as other physical risks covered under the Condition of Participation (CoP) for patient rights to care in a safe setting.

However, since participating in the The Joint Commission panel, CMS officials now think its own panel would be redundant. “CMS felt that to repeat the work of TJC Suicide Panel (in which CMS participated) would not provide any substantive additional gains and would not be a productive use of the time and expertise of the participants,” according to the newest memo.

CMS is still working to revise the interpretive guidelines for its surveyors but referred regional offices for now to expectations set out in its Dec. 8 memo on clarifying ligature risk, S&C 18-06-Hospitals (ECL 1/1/18). That memo carried extensive guidance, including an initial update to parts of the interpretive guidelines found in Medicare’s State Operations Manual, Appendix A (SOMA).

Expect more changes in the future, though. In the most recent memo, CMS said it would continue to work on updates to Appendix A as well as Appendix AA, guidelines for surveyors at Psychiatric Hospitals, “which will incorporate the standards that were recommended via the collaborative work of the The Joint Commission Suicide Panel Special Report: Suicide Prevention in Health Care Settings.” The memo provided an online link to the November The Joint Commission recommendations.

Written by A.J. Plunkett

CMS’ severe sepsis bundle ISN’T a Joint Commission requirement

The April 17 issue of Annals of Internal Medicine (AIM) incorrectly stated The Joint Commission was considering creating a requirement for hospitals to implement CMS’ Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) to receive accreditation. This information is incorrect and AIM has published a correction.

CMS Inpatient-Only List: Preparing for Critical Changes in 2018

Each year CMS revises its inpatient-only list of approximately 1,700 procedures. The most notable changes to the list that went into effect January 1, 2018 include the addition of coronary revascularization during an acute myocardial infarction and the removal of total knee arthroplasty. Knee replacements, according to CMS, now may be performed on either an inpatient or an outpatient basis.

These list revisions are vital for hospitals to track and take into account. For example, “removing knee replacement surgery from the inpatient-only list is going to cause major changes for hospitals and physicians who do these procedures,” says Kurt Hopfensperger, MD, JD, vice president of compliance and physician education at Optum Executive Health Resources. Moving forward, they will have to apply utilization review processes more rigorously.

Keeping pace with change

Hospitals that closely follow and interpret the CMS inpatient-only list benefit in several ways. The list follows evidence-based medicine and looks at the average length of stay, as well as typical risks and comorbidities, for each procedure. Thus, correctly placing a patient in inpatient status is a clinically good decision, and it helps organizations stay in compliance with Medicare rules.

Hospitals also protect revenue by making sure every patient undergoing a procedure on the inpatient-only list has a correct status determination, says Hopfensperger. As procedures drop off of the list, hospitals must do the same to avoid potential revenue integrity issues. “You want to make sure you are appropriately compensated for those patients who are high risk or who require a longer stay in the hospital,” he notes.

Continued at Health Leaders Media

CMS and Joint Commission change hospital eligibility requirements

Both organizations have changed their expectations on the defintion of a hospital. CMS’s new S&C Memo 17-44-Hospitals says that surveyors will use average daily census (ADC) and average length of stay (ALOS) data to determine if the hospital is primarily engaged in providing services to inpatients, and “a hospital must have inpatients at the time of survey in order for surveyors to directly observe the actual provision of care and services to patients, and the effects of that care” to determine if the facility is meeting the Conditions of Participation (CoP) in Medicare.

In addition, both CMS and The Joint Commission say that hospitals will need at least two active inpatients on site for an accreditation survey to be done. This change is effective immediately.

Main manual for CMS’ hospital Interpretive Guidelines updated

For the first time in two years, the online version of CMS’ State Operations Manual, Appendix A — also known as SOMA by some — is showing it has been revised!

The date on the appendix, which offers CMS surveyors Interpretive Guidelines to follow when implementing the hospital Conditions of Participation (CoP), is now Nov. 17, 2017. The last revision had been in November 2015.

The most recent update appears to mainly reflect changes to how CMS defines a hospital for survey. Those changes were announced in S&C memo 17-44-ALL-Hospitals.

And more changes should be on the way, especially in light of the recent publication of a new S&C memo on ligature risk. Among other things, S&C 18-06-Hospitals memo notes changes under Tag A-0701 that appear to delete references to emergency preparedness — now under their own set of CoP outlined in Appendix Z— and adds guidelines for checking out other physical safety concerns along with ligature risk within the environment of care.

CMS Emergency Prep rule is now enforceable by surveyors

It’s finally here.

CMS’ new Emergency Preparedness rule went into effect on Wednesday, November 15, which means surveyors can now cite facilities who aren’t compliant with the rule’s requirements.

The rule closes gaps in CMS’ previous regulations, such as requiring facilities to have contingency planning in place, emergency response training for staff, and communicate and coordinate their emergency plans with other hospitals and government agencies at the tribal, local, regional, state, and federal levels. Facilities have had over two years to prepare for this rule, and the agency has already said it won’t be accepting excuses for noncompliance.

While the rule itself is new, Steve MacArthur, a safety consultant at The Greeley Company in Danvers, Massachusetts, says that a lot of the new requirements are things that hospitals should have already been doing.

“I suppose I should stop and say that while this rule is new to the ‘marketplace,’ there are really no new concepts contained therein,” he says. “This may provide some guidance for CMS surveyors as they drill down on organizational preparedness activities. But none of this is groundbreaking or in any way representative of a change in how hospitals have done, and will continue to do, business. [It’s] just another set of official ‘eyes’ looking through the compliance microscope.”

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