The Centers for Medicare and Medicaid Services (CMS) has alerted both accrediting organizations (AOs) and healthcare organizations of increased scrutiny and oversight of the AOs. This means that state agencies and accrediting organizations contracted to assess compliance with the Conditions of Participation (CoPs) for deeming status will be increasingly vigilant to healthcare organizations’ compliance with CoPs.

Read more in Fierce Healthcare: CMS announces plans to ramp up oversight of hospital inspection agencies

According to the press release from CMS, oversight will be increased in three ways:  1) the public posting of AO performance data; 2) a redesigned process for AO validation surveys and 3) the release of the Annual Report to Congress.

How can healthcare organizations prepare for this increased scrutiny?

First and foremost, healthcare organizations should focus on areas of vulnerability in frequently cited and high-risk clinical areas, including but not limited to…

Be alert to the increased sensitivity to patients’ complaints and public information posted in the media about adverse incidents in hospitals. Additionally, prepare for increased frequency of unannounced surveys, comprehensive evaluations, and on-site assessments focused on areas of high risk to patient safety. Increase organizational self-assessment for compliance with frequently cited accreditation standards and CoPs as well as causes of Immediate Jeopardy. Establish a culture of ongoing survey readiness.


Compass Clinical Consulting is available to assist you and your healthcare organization before, during, and after survey. No matter your current state of readiness, we’ve been there, and we can help.

Our team of nationally recognized consultants are experts in accreditation and regulatory compliance and are uniquely qualified to partner with your healthcare organization. Contact our office at (513) 241.0142, via email, or via the contact page of our site for a confidential discussion of your needs and how we can partner with you to establish a culture of ongoing readiness.

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