Accrediting organization proposed rule fact sheet

Feb. 13, 2024
Strengthening CMS oversight of accrediting organizations.

The Centers for Medicare & Medicaid Services (CMS) released a Notice of Proposed Rulemaking (NPRM) on February 8, 2024 to bolster oversight of Accrediting Organizations (AOs) and ensure providers meet health and safety standards so that patients can receive high-quality, safe care from our nation’s healthcare facilities.

The most recent AO oversight report to congress (RTC), the 2021 RTC, covers the 2020 oversight and validation activities for all AOs in fiscal year 2020, as well as those under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).     

The proposed changes, which align with CMS’s National Quality Strategy, are outlined below:

  • Holding AOs accountable to the same standards as State Survey Agencies (SAs), that also conduct surveys on behalf of CMS.
  • Ensuring that AOs remain independent reviewers by addressing conflicts of interest and placing certain limitations on the fee-based consulting services AOs provide to the healthcare facilities they accredit.
  • Preventing AO conflicts of interest by prohibiting AO owners, surveyors, and other employees, and as well as their immediate family members that have an interest in or relationship with a health care facility accredited by the AO from participating in surveys, having input into the survey results and involvement in pre- or post-survey activities of that facility, or from having access to survey records related to that facility.
  • Addressing potential and actual conflicts of interest by requiring AOs to report specific information to CMS about how they will monitor, prevent, and handle conflicts of interest and fee-based consulting services they provide.
  • Improving AO performance by requiring AOs with poor performance to submit a publicly reported correction plan to CMS.
  • Improving consistency and standardization in surveys nationwide by more closely aligning AO survey activity requirements and staff training with those of SAs.

Additional changes proposed in the NPRM would reduce the burden on providers, strengthen survey policies, and increase the transparency of AO practices.

Currently, CMS has approved nine AOs to survey and accredit Medicare-certified facilities. The changes outlined in the NPRM affect all AOs except those that accredit clinical laboratories and noncertified suppliers, which include suppliers of advanced diagnostic imaging (ADI), home infusion therapy (HIT), and diabetes self-management training (DSMT), as well as durable medical equipment (DME) suppliers and suppliers of durable medical equipment prosthetics, orthotics, and supplies (DMEPOS).

Additional details on the proposed changes in this rule are described on the CMS website.

CMS release