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QUAD AOct 19, 2023 9:16:13 AM2 min read

Unannounced Surveys, Exclusions, Complaint Investigation Applicability

The Centers for Medicare & Medicaid Services’ (CMS’) Quality, Safety & Oversight Group, has identified inconsistencies related to the comparability of survey processes used by Accrediting Organizations (AOs) versus the State Agencies (SAs). The following guidance has been provided by CMS as part of their ongoing efforts to improve patient health and safety by increasing consistency in the survey process used by all AOs.

Unannounced surveys - CMS is aware that some AOs are notifying facilities of the AO survey team’s arrival prior to arriving onsite. These notifications or announcements were usually done via email or electronic portal preceding a survey team’s arrival onsite at the facility by minutes or days. However, QUAD A will continue its fully unannounced survey process and not contact the facility prior to the surveyor or survey team’s entrance into the facility. Any prior notice of a survey, via email, electronic portals, phone calls, or other means of communication, is considered a violation of CMS regulations.

QUAD A will continue conducting administrative business practices (such as gathering relevant information on the facility’s demographics, operating hours, surgical schedules, etc.) prior to conducting a survey. However, these administrative communications will not announce or indicate when a survey will occur.

Exclusion Dates - CMS is aware that some AOs allow facilities to request “blackout dates,” which are dates the facility requests or prefers not to be surveyed. Allowing facilities to request dates when they wish not to be surveyed is not consistent with CMS’ survey expectations. CMS believes that the facility must always be “survey ready.” If an AO learns that a facility has a situation that would decrease the efficacy of an onsite survey (such as a sole practitioner who will not be at an ASC and no surgeries will be performed that day), the AO may pick an alternate date. This decision, however, rests with the AO and must not be driven by the facility. QUAD A will not be able to accept exclusion (“blackout”) dates or weeks.

Complaint Investigations - CMS has found that many AOs contact facilities prior to onsite investigations, or conduct offsite complaint investigations, both of which are inconsistent with the CMS requirements. QUAD A will continue its practice of not contacting the facility prior to the onsite investigative survey. QUAD A will continue with its unannounced Investigative Survey process and will continue to protect the confidentiality of the complainant and others involved.  QUAD A will explain the reason for the survey as well as any information about the complaint or the complainant and will protect the confidentiality of those involved in the complaint.

If you have any questions regarding this newsletter, please do not hesitate to contact your QUAD A Accreditation Specialist or info@QUADA.org. 

QSO Policy Memorandum 09-41 DEPARTMENT OF HEALTH & HUMAN SERVICES (cms.gov) 
CMS Letter Issued to All AOs on June 16, 2023 

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.