CMS clarifies survey oversight for condition-level noncompliance

On March 25, the Centers for Medicare & Medicaid Services (CMS) issued revised memo QSO‑18‑12-Deemed Providers/Suppliers to clarify the roles of accrediting organizations (AOs) and state survey agencies (SAs) when a provider’s or supplier’s Medicare-deemed status is temporarily removed due to condition‑level noncompliance.

CMS may temporarily remove deemed status when an SA or federal survey team identifies condition‑level deficiencies. When this occurs, the CMS location formally notifies the organization and places it under the jurisdiction of the state survey agency, rather than the AO.

The revised memo reinforces that accrediting organizations must suspend or postpone Medicare deeming recertification surveys while deemed status is removed. Importantly, CMS clarifies that if a provider’s regular 36‑month accreditation cycle lapses during this period, the AO will not be cited as late or noncompliant for missing the survey.

CMS also notes that while non‑deeming accreditation surveys are not prohibited during state oversight, CMS recommends postponing these activities to avoid confusion or duplication while the organization works toward regaining compliance.

The revised guidance also provides additional clarification on complaint investigations, emphasizing the need for coordination between SAs and AOs. During temporary removal of deemed status, the SA maintains primary responsibility for investigating complaints, while keeping the AO appropriately informed.

Why this matters for facilities

For hospitals and health systems, including facilities and physical environment leaders, the memo underscores the importance of understanding who has regulatory authority during periods of noncompliance. While temporary loss of deemed status due to a state survey agency or federal team survey does shift oversight of follow-up activities it does not penalize organizations or their AOs for unavoidable survey delays while corrective actions are underway.

Leah Hummel, AIA, CHFM, SASHE, CHC, CHOP, is senior associate director of ASHE Regulatory Affairs.