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CMS Rule Would Make Accreditors' Hospital Inspection Reports Public

Private health care accreditors don't make their survey reports and accompanying plans of correction publicly available. "We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements found in survey reports publicly available," CMS says in the proposed rule.

Private accrediting organizations' reports of hospital facility inspections and cited facilities' plans of correction may soon be available to the public, if a rule being proposed this month by the Centers for Medicare and Medicaid Services (CMS) is implemented. Available online prior to its publication later this month, the gargantuan rule fills more than 1,800 pages. More than 1,400 pages into it, CMS explains why it wants the information to be made public.

State survey agencies compile reports on health facilities' compliance with Medicare conditions using CMS Form 2567, "Statement of Deficiencies and Plan of Correction." If deficiencies are cited, a facility must submit an acceptable plan of correction (PoC) for achieving compliance. CMS makes survey reports and acceptable PoCs publicly available; it began posting redacted Form 2567 survey data for skilled nursing facilities and nursing facilities on its Nursing Home Compare website in July 2012 and in March 2013 began posting survey reports based on complaint investigations for short-term acute care hospitals and critical access hospitals.

Accrediting organizations (AOs) perform their own accreditation surveys and issue their own survey reports on accredited facilities' compliance with federal standards—hospitals, psychiatric hospitals, critical access hospitals, home health agencies, hospices, ambulatory surgery centers, outpatient physical therapy and speech-language pathology services, and rural health clinics. These facilities participate in Medicare based on their accreditation from a CMS-approved AO and are not subject to routine surveys from state survey agencies, and the AOs don't currently make public their survey reports and accompanying PoCs.

"We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements found in survey reports publicly available through our various provider and supplier Compare sites, including hospital and home health Compare sites to increase transparency," CMS says in the rule.

CMS notes there has been rising concern about disparities between AOs' deficiency findings and the serious, condition-level deficiencies found by the state survey agencies, saying it "raises serious concerns regarding the AOs' ability to appropriately identify and cite health and safety deficiencies during the survey process. Therefore, we believe that posting AO survey reports and acceptable PoCs would address some of the concerns of reporting hospital information from both CMS and AOs, as well as the disparity between serious deficiency findings, and provide a more comprehensive picture to health care consumers and the public in general."

In addition, the number of survey reports and acceptable PoCs that are available to health care consumers is dropping, CMS said, given that 89 percent of hospitals and psychiatric hospitals across the country participate in Medicare via accreditation and deemed status: "This represents a significant number of hospital and other health care facility survey reports and acceptable PoCs that are currently not available to health care consumers. This information is not available to assist health care consumers in their decision making when selecting a health care facility in which to receive care for themselves or a loved one. Therefore, we believe that it is critical that accrediting organizations with CMS-approved accreditation programs make available publicly all survey reports and acceptable plans of correction on their websites."

OH&S Digital Edition

  • OHS Magazine Digital Edition - November 2017

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