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CMS Direct Observation Validation Surveys: Ensuring Federal Standards Compliance

CMS Validation Surveys play a pivotal role in maintaining the integrity of accreditation organizations (AOs) and ensuring compliance with federal standards. The purpose of validation surveys is to assess the AO鈥檚 ability to ensure compliance with Medicare conditions.

CMS has contracted with two national organizations to conduct validation surveys, sending their surveyor(s) to directly observe the AO surveyor(s). The new approach is designed to prevent the need for a separate survey of the health care organization, and to focus on evaluating 麻豆传媒鈥檚 ability to assess compliance with the Conditions of Participation.

Proportion of Deemed Facilities Receiving Validation Surveys

Number of validation surveys
Number of deemed facilities
Proportion of deemed facilities receiving validation surveys

Disparity Rate: A Crucial Metric in Evaluation

After the accreditation survey is completed, the contractor survey observers will submit their observation via worksheet to CMS Baltimore. The goal of this validation analysis is to determine whether the AOs are able to accurately identify serious deficiencies in a facility.

The disparity rate focuses on the number of validation surveys where the AO did not cite comparable condition-level deficiencies, as identified by contractor survey observers. The disparity rate is calculated concerning the total number of validation surveys completed.

Disparity Rate Calculation

Number of AO surveys with missed condition-level deficiency findings
Number of validation surveys
Disparity Rate

Key Distinction: Disparity Rate vs. Standards Alignment

It's crucial to clarify that the disparity rate is not a measure of how closely an AO's standards align with CMS regulations. Instead, it specifically addresses variations in condition-level deficiencies identified during the validation process.

There are, however, limitations when discussing disparity rates. The disparity rate does not solely measure the AO鈥檚 performance. Additionally, a high AO disparity rate does not necessarily indicate unsatisfactory performance by the AO. AO program types having smaller sample sizes may result in higher AO disparity rates.

Continuous Improvement and Collaboration

Understanding these metrics is essential for continuous improvement. By recognizing and addressing disparities, AOs can collaboratively work with CMS to enhance the consistency and quality of healthcare services. Embracing these metrics presents an opportunity to foster an environment of shared learning and improvement. Collaboration with CMS becomes a catalyst for positive change, ensuring a healthcare landscape marked by excellence.

CMS Validation Surveys Resuming in 2024

Historically, state agencies conducted 鈥渓ook back鈥 validation surveys within 60 calendar days following AO surveys. Moving forward, CMS contracted with two national organizations to conduct validation surveys, sending their surveyor(s) to directly observe the AO鈥檚 surveyor(s). The new approach is designed to prevent the need for a separate survey of the health care organization, and to focus on evaluating the AO鈥檚 ability to assess compliance with the Conditions of Participation. CMS expects to do fewer of these direct observation validation surveys compared to the "look back" validation surveys.

The national contracted organizations will send the same number of surveyors as the AO鈥檚 survey team to ensure that each surveyor is observed throughout the triennial deemed survey. The CMS鈥揷ontracted surveyors will not conduct a separate survey or issue a CMS 2567 survey report. All survey findings will be identified by the AO鈥檚 survey team and captured in the survey report, and health care organizations will respond to the AO for any identified findings.

CMS has . For detailed information about accrediting organizations' disparity rates and survey data, we encourage you to visit the .

Understanding and harnessing the significance of CMS Disparity Rates within Joint Commission accreditation is a strategic step towards fostering a healthcare environment marked by continuous improvement, transparency, and unparalleled patient care.