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Validation surveys can uncover array of physical environment problems


December 21, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

CMS wants The Joint Commission and other accrediting organizations (AOs) to crack down on problems within the physical environment after another disappointing review of AO performance.

That’s after CMS reported to Congress on the number of problems state agency surveyors found in validation surveys within 60 days of an AO visit in fiscal 2017 (if you missed it, see the November HSL). 
So what is CMS finding on validation surveys that is so concerning?

CMS provides a quarterly update of deficiency reports from its state survey agencies (SA). However, the reports in the database from fiscal year 2017 are not always clear when a CMS visit is for a validation survey or to investigate a complaint.

In 2018, CMS created a new online database, highlighting what it deems the most serious deficiency reports, sorted by state or by accrediting organization (AO). The Quality, Certification and Oversight Reports database, or QCOR for short, generally maintains about six months of reports.

According to a statement on the site, “Hospitals participating in Medicare and Medicaid receive onsite surveys by State Survey Agencies and private Accrediting Organizations to ensure compliance with Federal Regulations. When the survey agency or Accreditation Organization finds a hospital not to be in compliance, it cites a deficiency and issues a survey report that summarizes the findings.”

“This website lists all hospitals who were found to be substantially out of compliance during a State Survey Agency survey in the last six months and provides the survey report for public review,” says the site.
If you select a particular AO, the site will list all those reports and show whether the survey was because of a complaint or a validation survey.

Here are examples of what CMS is finding on validation surveys, according to a sampling taken in mid-September. Because these reports are only from within the last six months, they do not include deficiencies outlined in CMS’ report to Congress on AO performance.

The Joint Commission (TJC)

At any given time, QCOR will have substantial deficiency survey reports on a few dozen hospitals who use TJC for accreditation. However, TJC also conducts almost 90% of the hospital surveys each year. Given that CMS conducts validation surveys of a comparatively tiny percentage of hospitals—in FY 2017, it handled only about 3% of the 1,295 hospitals facing initial renewal surveys—it would stand to reason the majority of reports in QCOR are for TJC-accredited hospitals.

Of 105 TJC-accredited hospitals listed on QCOR in mid-September in which CMS surveyors had found what they considered substantial deficiencies, only five were validation surveys conducted within 60 days of a renewal or initial survey or, if part of the pilot project to improve how CMS assesses AO performance, conducted at the same time as the AO. One survey report was for a recertification for Medicare, and the rest were complaint investigations.

While not every CMS survey resulted in an immediate jeopardy (IJ) situation that threatened the hospital’s ability to bill Medicare, all five of the validation surveys were ruled IJs.

One example involved a three-facility health system in Arkansas. TJC’s Quality Check database of accredited hospitals shows TJC did a renewal survey at the hospital in April 2019, with a follow-up survey six weeks later. Quality Check does not indicate what the follow-up survey covered.

A CMS team showed up the first week of June, and one day into the three-day visit discovered a freestanding bathtub in a low intervention birthing suite. The tub was “adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub,” according to the CMS survey report. CMS deemed this to be a hazardous environment with the potential to have endangered previous patients and any new patients treated in the room.

The facility’s director of maintenance was informed the hospital was considered to be in an IJ situation. The IJ was lifted the next day, after the room was taken out of clinical service and a “certified electrician removed three electrical receptacles, replaced one of the electrical receptacles with an approved hospital-grade GFCI (Ground Fault Circuit Interrupter) located greater than five feet from the water source.” The massage chair and refrigerator also were removed from the birthing suite.

One of CMS’ concerns appeared to be that the tub had been installed six months before the validation survey.

Other concerns during the survey included a review of medication errors in the previous year in which CMS surveyors found that the charts of two out of five patients were not updated to show the administration of incorrect medications. In another records review, the hospital did not follow established respiratory care services policies and procedures in putting a tracheostomy patient on a ventilator dehumidifier. Neither of those concerns rose to the level of an IJ.

A second example involves a hospital in New Jersey that TJC surveyed and accredited in April. CMS surveyors showed up two months later for a validation survey, and found several deficiencies, including not having manufacturer’s instructions for surgical instruments immediately available and the discovery of single-use vials of medication being given to more than one patient. Both resulted in separate IJs called by CMS surveyors, according to the CMS report.

Several other concerns with pre-drawn medications, sanitary problems in the kitchen, and other infection control issues with surgical instruments were among other deficiencies identified. Both CMS and TJC surveyors would return to the hospital multiple times over the next few weeks.

In another instance, a hospital in Oklahoma had to correct a litany of problems to mitigate patient-harm risks on a patient unit, including eliminating several ligature risk issues, moving patients closer to nursing stations, and reeducating the staff on 1:1 observation of patients at high risk of self-harm.


HFAP, which deems 139 hospitals, had only three reports on the QCOR database, one of which was from a validation survey at a hospital in New York in May. HFAP does not indicate on its website when it surveyed a hospital, only that the hospital is accredited.

At that hospital, CMS identified an IJ because “the facility failed to ensure egress pathways were appropriately marked and accessible in the event of an emergency situation. Specifically, the use of magnetic door holds that do not release with activation of the fire alarm or sprinkler system and exit signage directing individuals towards the magnetically held doors.”

The IJ was removed two hours later after the magnetic door holds were removed and an acceptable egress pathway was sufficiently identified and marked.

Other problems identified during the survey were pain reassessments that were not being done according to hospital policy, out-of-date or undated medications, and lack of a fire prevention policy in the surgical suite.

DNV-GL Healthcare

DNV-GL, which accredits 466 hospitals, had 10 complaint surveys on QCOR but no validation surveys. Of the 10 complaint surveys, three involved IJ situations.

Center for Improvement in Healthcare Quality (CIHQ)

There were no CMS reports for CIHQ in mid-September. The QCOR site did note that CIHQ accredits only 68 hospitals.


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