CMS Releases Updated Guidance for Surveys During the COVID-19 Public Health Emergency

AHA Special Bulletin
January 20, 2021

The Centers for Medicare & Medicaid Services (CMS) today released updated guidance putting in place certain limitations on the hospital survey process, including limiting onsite surveys to immediate jeopardy complaint allegations. The limitations will remain in effect for 30 days with the potential for renewal of the guidance in additional 30-day increments, CMS said. The AHA had asked CMS to eliminate surveys or at least severely limit them while hospitals are dealing with significant surges in patients who are severely ill with COVID-19.

The survey limitations established by the guidance are separated into three categories:

  • Hospital Complaint Surveys. These surveys will be limited to immediate jeopardy complaint allegations with CMS prioritizing onsite investigations based on imminent danger to patients at the hospital, likelihood of noncompliance with the Conditions of Participation (CoPs), and whether immediate action must be taken to protect the health and safety of patients. The investigation will be limited to CoPs necessary to ensure the health and safety of patients in imminent danger. Further, CMS only will authorize infection control investigations when the allegations warrant such an investigation
  • Hospital Recertification Surveys. These surveys will be suspended, except for a subset of hospital reaccreditation surveys, which will be detailed in forthcoming guidance. In addition, accrediting organizations also will be directed to suspend reaccreditation surveys for 30 days and should expect to receive guidance in the near future with additional information about the reaccreditation survey process.
  • Hospital Enforcement Actions. Any deficiencies that do not represent immediate jeopardy will have their termination date extended for at least 30 days to remain consistent with the survey guidance. During this time, hospitals are expected to continue to ensure safety and quality, but will not be required to submit a plan of correction and will not receive a state survey agency revisit. For those hospitals with an uncorrected incident of immediate jeopardy, they must demonstrate removal of such immediate jeopardy through an onsite survey. Hospitals can expect additional guidance on enforcement.


If you have questions, please contact AHA at 800-424-4301.

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