CMS provides guidance on two surveyor updates

CMS cautions hospitals about patient safety work products

The Centers for Medicare & Medicaid Services issued QSO-23-24-Hospital Sept. 29 providing additional guidance regarding patient safety work products (PSWP) and the impact these could have on survey findings. 

The QSO states: “When a hospital chooses to identify documents and materials as PSWP, surveyors should not demand disclosure of these documents or materials. However, hospitals will be expected to produce appropriate evidence of compliance that can be reviewed by the on-site surveyors. Hospitals that do not have a method of documentation to demonstrate compliance or that place information into a Patient Safety Organization may risk being cited for deficiencies and be subject to enforcement actions as a result.”

Discussing PSWP usage and how it could impact documenting compliance for Conditions of Participation with quality assurance leadership will help to avoid documentation needed to verify compliance becoming PSWP.

For additional information see QSO-23-24-Hospital.

CMS announces that REH Surveys will be SA conducted

On Nov. 23, 2022, the Centers for Medicare & Medicaid Services (CMS) published a final rule (87 FR 72293) that established rural emergency hospitals (REHs) as a new Medicare provider type.

On Nov. 3, 2023, CMS posted QSO-24-01-REH stating that, “All REH surveys will be conducted by State Survey Agencies (SAs) for at least the first three years from the date on which the first REH has been certified.” This is to allow CMS to have “adequate time and opportunity to effectively monitor and evaluate the program”.

For additional information see QSO-24-01-REH.