CMS makes changes to its citation methodology

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2019 Hospital Construction Survey

The stories about controversial interpretations of codes and potentially conflicting codes are reflective of issues that have long plagued health care construction. But Chad Beebe, CHFM, FASHE, ASHE’s deputy executive director for advocacy, points to another reason compliance is such a big issue today: The Centers for Medicare & Medicaid Services (CMS) changed how it determines when a citation is necessary.

“CMS changed their methodology about two years ago — and required accrediting organizations to do the same. Now it’s a ‘see it, cite it’ methodology,” Beebe says. “In the past, a lot of accrediting organizations allowed the facilities to show that they had a management plan in place to routinely repair things. In those cases, the issues would not have led to citations.”

But today, even minor issues are leading to citations. In a hospital environment, minor repair issues are constantly cropping up, and as long as the facilities department has a plan to address them, there’s little or no danger to safety. None of these single life safety deficiencies make a building unsafe, Beebe notes. But constantly citing these minor problems not only increases the cost of compliance, it also changes how hospitals handle the issues.

“My concern is that facilities will adjust their management principles and focus more on trying to just take care of citations as opposed to managing those items over the long term,” he says. “This changes the focus to putting out the fires rather than preventing them.”