The Centers for Medicare & Medicaid Services (CMS) has responsibility for oversight and approval of accrediting organization (AO) accreditation programs used for Medicare certification purposes, and for ensuring that providers or suppliers that are accredited under an approved AO meet the quality and patient safety standards required by the Medicare Conditions of Participation.

On Dec. 15, 2021, CMS issued its annual report to Congress, “Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program,” which details the review, validation and oversight of the FY 2019 activities of the approved AOs’ Medicare accreditation programs as well as the CLIA Validation Program. While the report provides a significant amount of information, American Society for Health Care Engineering members might find Section 4, Validation of Accrediting Organization Surveys and Section 5, Life Safety Code, Health & Safety Disparity Rates Analysis and Complaint Survey Citations, of particular interest.

Section 4 indicates that while the overall disparity rate for hospital surveys decreased 5% there was a significant increase in survey disparity rates for both psychiatric hospitals (7%), and critical access hospital (CAHs) (5%). Additionally, this section details that state agencies (SAs) identify more physical environment condition-level deficiencies than any other type of deficiency on validation surveys. With this concern, CMS has indicated in the report that the validation redesign pilot (VRP) program, in which a SA surveyor has direct observation of AO surveyors during survey activity, is tentatively scheduled to restart in FY 2022.

In Section 5 CMS reported that the physical environment (PE) and infection control conditions are the top disparate citations for hospitals, psychiatric hospitals, ambulatory surgery centers and CAHs. While the PE condition contains multiple standards, a large majority of the PE citations were comprised of the Life Safety Code (LSC) standard within the condition. Within the LSC standard the following categories comprised the top deficiency citations not cited by AOs: fire/smoke barrier, hazardous areas, sprinklers and means of egress.