Unannounced Surveys and Complaint Reviews by Accrediting Organizations

on the radar alert

In a memorandum dated June 16, 2023, the Centers for Medicare and Medicaid Services (CMS) informed Accrediting Organizations (AOs) that some survey practices are inconsistent with State Operations Manual instructions. Here are the key points:

  • Surveys must be unannounced with no notifications prior to surveyors being onsite. Modes of prohibited notification include electronic portal, email, and phone call.
  • Blackout dates will no longer be honored. Organizations cannot request “blackout dates” that indicate their request for no survey activity.
  • Offsite or administrative reviews of complaints are generally not allowed. This means that organizations should expect the review of complaints to occur onsite, either expedited if a complaint is triaged at an immediate jeopardy level or no later than the next onsite survey if a complaint is non-immediate jeopardy level at low or medium.

These updates underscore CMS’ expectation of continuous survey readiness. In response to this memorandum, Accrediting Organizations must review their practices and submit any needed revisions to their policies and processes by July 14, 2023. We recommend accessing this information from your Accrediting Organization and watching for updates, especially on how surveyor identification can be verified when a survey occurs.

Organizations should review their survey readiness/execution plan and ensure:

  •  A consistent process for verifying surveyor identification upon arrival to your organization and an up-to-date call tree to inform leaders of the survey start is in place.
  • Ready availability of the Survey Document Binders that contain the required documents for surveyors to review. Having the document binders readily available, complete, and up-to-date are essential first steps to a successful survey. Ensure multiple leaders know where the Required Document Binders are housed for immediate delivery to the surveyor’s office.
  • A solid plan for where the surveyor’s office will be and the understanding that their presence trumps any other meetings scheduled for that location.
  • The expectation for every leader/department head to have at least 2 people that can lead the organization/department through the survey in their absence.
  • A well-defined written Survey Guidance and Command Plan that can be distributed and followed in the absence of those who would normally make the survey process happen seamlessly.

How survey-ready is your organization?

 Please contact Courtemanche and Associates for questions or assistance in maintaining continuous survey readiness at 704-573-4535 or info@courtemanche-assocs.com.

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