CMS Complaint Survey Process

The CMS complaint survey process changed. And, they introduced a new validation survey pilot. Here’s how it will impact your organization.

CMS Complaint Survey Process

The CMS issued an important new memo QSO-19-01 that accomplishes three things:

1. Identifies a new website where consumers can locate CMS complaint information and survey findings
2. Includes this year’s annual report to Congress on the validation survey findings
3. Discusses a new method for performing validation surveys that’s in pilot. It involves simultaneous or concurrent teams from the accrediting body and CMS surveying

You can find the memo here.

Readers should look at this new database of survey findings the CMS created. It is simple to navigate. In fact, all consumers and reporters need are basic Internet skills. You can easily find readable versions of any complaint surveys found at your organization.

In prior editions of this newsletter, we discussed the American Health Journalists website and the CMS quarterly spreadsheet of all findings. Neither were as easy to navigate as this new website.

In addition, here is a key consideration for hospital leaders. A public posting of the CMS2567 findings will occur after a complaint survey. So, it’s important to develop a communications or media strategy in conjunction with your plan of correction. The link to this website is in the CMS QSO memo.

The Wall Street Journal Weighs In

A Wall Street Journal article on October 5, 2018 described the origin of this new CMS website service as an outgrowth of their article in 2017. It identified that the Joint Commission “took no action” when the CMS conducted complaint surveys and found serious deficiencies.

While true, this conclusion was also misleading. The Joint Commission did not know the conditions changed. Or, that the CMS found deficiencies due to the missed or delayed sharing of information.

By displaying it on a public website, the CMS will share the information in a more timely basis. Now TJC and the individual hospital can be embarrassed together. We assume TJC will monitor this public website for new reports. And, they may send out their own teams to investigate the findings.

The Report To Congress

The report to Congress summarizes what the CMS found during its validation surveys at various types of organizations accredited by a deemed status accrediting body.

The introduction to this report is very informative. The CMS states that it views its complaint surveys as part of the validation process. This helps to explain why the serious findings in accredited hospitals during complaint surveys infuriated both the CMS and WSJ.

We assumed that conditions could change in a three-year accreditation cycle. For example, issues identified today may not have existed three years ago when the accreditor was present. Plus, the statement that the CMS also views the complaint survey findings as a component of the validation process implies this.

But instead, it appears they believe this about the accreditor. If they had their finger on the pulse of the organization, such conditions should not materialize throughout the three year accreditation cycle.

It will be interesting to see where this leads. It may result in a concept discussed by TJC many years ago. This includes smaller footprint surveys conducted with greater frequency. The CMS also detailed information in their 2017 report to Congress. It did not include the complaint survey findings in the mathematical calculation of disparity rates.

Most of the report to Congress discusses what the CMS found and accreditors did not. In addition, it provides feedback on more routine performance measures and expectations. This includes accreditors sharing schedules and survey reports with the CMS on a timely basis. For the most part, these performance measures are adequate for information sharing from the accreditor to the CMS. There is no performance measure for CMS sharing information with the accreditor.

The Key Metric

But, here is the key part of the report. For the same institution surveyed within 60 days of each other, it notes discrepancies between the CMS and the accreditors. Based on their analysis of 2016 surveys, the CMS found a discrepancy rate for hospitals accredited by TJC of 44%. This discrepancy splits equally between physical environment and clinical findings.

You might remember in past years the disparity centered in the physical environment. But, given the increased days for TJC life safety code surveyors and the huge numbers of EC/LS findings, this improved. The reporting discrepancy in clinical finding is in infection control, governing body, QAPI, and nursing. This means CMS surveyors are finding more condition level issues in these four areas than is TJC.

We have all seen lots of TJC scoring in IC and LD these past few years. But, the number of condition level findings is going to have to increase even more to reduce the disparity rate. QAPI and nursing may be more of a struggle, as the PI and NR chapters are not scored very frequently. TJC may need to develop a strategy for secondary hits in those chapters, similar to what they already do with LD.