TJC & CMS News Blog
Information for

In an ongoing effort to ensure the highest standards of quality and safety in healthcare facilities participating in Medicare and Medicaid programs, the Centers for Medicare & Medicaid Services (CMS) has proposed significant changes to enhance its oversight of Accrediting Organizations (AOs). Published on February 8, 2024, a Notice of Proposed Rulemaking (NPRM) details changes to boost patient safety, strengthening oversight of healthcare accreditation. These changes aim to make survey processes more consistent nationwide.

Concerns about Accreditor Performance

There is no doubt that Accrediting Organizations play a crucial role in healthcare. They accredit over 9,000 healthcare providers and suppliers each year. This ensures compliance with federal health and safety requirements. Yet, there are increasing concerns about AO performance. This includes cases where facilities, despite major quality and safety problems, kept their accreditation after being removed from Medicare/Medicaid programs. In addition, some AOs offer fee-based consulting services to the same facilities they accredit which could compromise the integrity of onsite surveys.

CMS’s annual Reports to Congress (RTCs) have underscored these concerns, prompting the agency to act. The proposed rule aims to address these issues comprehensively. It includes provisions to hold Accrediting Organizations to the same standards as State Survey Agencies (SAs), ensure their independence, and enhance consistency and transparency in survey processes.

Strengthening Oversight of Healthcare Accreditation – Key Provisions of the Proposed Rule

  • Holding AOs accountable to standards aligned with Medicare Conditions of Participation (CoPs) and Requirements.
  • Addressing conflicts of interest by placing limitations on fee-based consulting services provided by Accrediting Organizations to accredited facilities.
  • Strengthening AO performance evaluation and competency assessment of surveyors.
  • Enhancing enforcement measures, including consequences for violating conflict-of-interest provisions.
  • Increasing transparency through publicly reported plans of correction for poor AO performance.
  • To ensure health and safety, align AO survey process requirements with SA standards and require that all types of deemed surveys be unannounced.
  • Reduce the burden on providers by revising validation programs by establishing direct observation of AO surveys and reducing look-back validation surveys by 50 percent.

Comment Period

Interested parties should comment on the NPRM before the close of the 60-day comment period on April 15, 2024. You can submit comments electronically through or via regular or express mail. Make sure to reference file code CMS 3367-P. Use this link to see the proposed rule.

In essence, the proposed rule represents a concerted effort by CMS to strengthen oversight of AOs. This will ensure that patients receive high-quality, safe care from accredited healthcare facilities across the nation.

Barrins & Associates Consultation

At Barrins & Associates we can assist you to develop a comprehensive accreditation and regulatory continuous compliance program. Inquire today about our consulting services. We continue to support your journey toward accreditation and regulatory compliance.

Barrins & Associates – Navigating Regulations & Accreditation Made Stress-Free with Our Expert Support!