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Recent Industry News

Health Care Compliance

The United States House of Representatives Committee on Energy and Commerce (House Committee) recently initiated an inquiry into the Centers for Medicare and Medicaid Services’ (CMS) oversight of CMS-approved private hospital Accrediting Organizations (AOs) and their hospital survey processes.  The House Committee is conducting this inquiry pursuant to its oversight authority over CMS and its role in ensuring patient safety and adherence to federal standards by hospitals participating in the Medicare and Medicaid programs.  Under the Social Security Act (the Act) and requirements from the Department of Health and Human Services (HHS), hospitals participating in the Medicare program are required to meet certain minimum requirements, known as Medicare Conditions of Participation (CoPs).  Hospitals can obtain such certification through CMS affiliated state agencies or through private AO accreditation.

Recent Developments

The House Committee’s inquiry was prompted by the publication of a Wall Street Journal (Journal) article that revealed that some hospitals were maintaining their accreditation despite exhibiting serious patient safety issues.  The Journal highlighted the case of Cooley Dickinson Hospital in Northampton, Massachusetts, where CMS reported that the hospital’s failure to provide quality medical care, as required in the CoPs, resulted in the death of all three patients.  Despite CMS’s finding, the hospital maintained full accreditation by TJC.  Subsequently, the Journal conducted an independent study and found that 350 TJC accredited hospitals were in violation of CoPs in 2014, but less than one percent had their accreditation revoked.  The Journal report, in addition to recent annual reports to Congress, instigated the current congressional inquiry.  Accordingly, the House Committee recently sent inquiry letters to CMS and four AOs including The Joint Commission (TJC), the Bureau of Healthcare Facilities Accreditation, the Center for Improvement in Healthcare Quality, and DNV GL Healthcare.

CMS issues the CoPs for hospitals participating in the Medicare program.  State Survey Agencies (SAs), acting on behalf of CMS, perform the Medicare certification process and inspect hospitals to ensure compliance with the terms of the CoPs.  However, hospitals may elect to obtain accreditation from a private, CMS-approved AO such as TJC, in lieu of seeking certification from SAs.  According to CMS’s most recent report to Congress, in Fiscal Year (FY) 2015, 89 percent of hospitals, 3,500 hospitals in total, chose to demonstrate compliance with CoPs through accreditation.

CMS’s Role in Accrediting Organizations

CMS is responsible for conducting oversight of AOs’ activities and reviewing their performance in surveying healthcare facilities.  To validate the AO hospital surveys, CMS uses its SAs to perform validation inspections on some hospitals that were previously surveyed by an AO.  The validation process produces a disparity rate which determines the percentage of AO surveys that missed a problem found during the corresponding CMS inspection.  Specifically, the disparity rate focuses on the number of 60-day validation surveys where the AO did not cite comparable “condition-level” deficiencies cited by SAs.  Under CMS’s definitions, “condition-level” deficiencies are considered the most serious type of deficiency because they indicate that a provider or supplier is not in compliance with an entire CoP.  If the disparity rate is above 20 percent, CMS must inform the accreditor of its performance.  For FY 2014, the disparity rate was 42 percent for hospitals, 75 percent for psychiatric hospitals, and 55 percent for critical access hospitals (CAHs).  In FY 2015, the disparity rate was 39 percent for hospitals, 69 percent for psychiatric hospitals, and 45 percent for CAHs.  AOs may use different measurement tools from CMS SAs to assess compliance with Medicare CoPs, accounting for some of the disparity.  However, the disparity rate remains significant enough to warrant further congressional oversight.

In addition to the reported disparity rates, the Journal’s independent study provides extra cause for concern.  The Journal’s study focused on TJC’s accreditation process.  The TJC is a prominent nonprofit organization that provides hospital accreditation for almost 80 percent of U.S. hospitals.  The Journal reviewed information on hospital violations provided by CMS, and compared hospital accreditation status on a TJC maintained website.  The Journal found that TJC does not typically take action to revoke or modify hospital accreditation, even when SAs identify serious safety violations during their validation inspections.  The Journal study revealed that of the 350 hospitals in violation of Medicare CoPs in 2014, nearly 60 percent  continued to have such violations in the preceding three years while maintaining their TJC accreditation.  Furthermore, in more than 30 instances in 2014, hospitals retained their full accreditation despite CMS deeming their violations so significant that they were likely to cause a risk of serious injury or death to patients.

Given the significant role AOs play in hospital accreditation, the House Committee seeks specific information to assess the adequacy of CMS’s oversight and validation process of AOs.  Specifically, the House Committee has requested documentation such as hospital Medicare accreditation program and renewal applications, performance reviews, validation survey feedback, corrective action plans, and correspondences between CMS and AOs addressing hospital disparity rates.

The House Committee’s news release is available at:

https://energycommerce.house.gov/news/press-release/ec-leaders-request-information-hospital-accreditation-processes/.