Frontline Hospice Staff Need to Understand New CMS Survey Methods

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Ensuring staff are educated around revisions to hospice survey processes will be key to navigating ongoing regulatory changes in the industry.

Revisions to hospice surveys have been in the pipeline for the last few years. The pandemic temporarily stalled the U.S. Centers for Medicare & Medicaid Services’ (CMS) efforts to revamp the process, aimed at improving the quality of care.


This year will bring further implementation of survey validation activities, but also new regulatory oversight processes, according to Kim Skehan, vice president of accreditation for the Community Health Accreditation Partner (CHAP) organization.

The changes could improve surveyors’ ability to recognize and address quality issues, Skehan said. This means hospices will need to fine tune their survey management processes with a firm grasp of how surveys will look going forward, as well as the pitfalls to avoid, she stated.

“Part of survey management is really understanding the regs and how the agency shows that they meet the standards,” Skehan said during a recent Husch Blackwell podcast. “And then really being on top of both all of those for hospice changes, all of ‘the red,’ [and] all of the pre-survey guidance. You can’t underestimate the benefit of having a true proactive survey management process, because that helps all of the staff in the field.”


The changes in a nutshell

CMS in 2021 announced revisions to its survey process to emphasize what the agency considers to be four core Conditions of Participation (COPs) — those most associated with the quality of care and services provided directly to the patient. These include rules pertaining to patient rights, initial comprehensive assessments, interdisciplinary care planning and care coordination.

In addition, CMS imposed new requirements for surveyor training and assessment tools, as well as conflict-of-interest protocols.

The agency included the hospice survey changes in its home health final rule for 2022. Congress mandated many of these provisions in the Consolidated Appropriations Act of 2021. Legislators added the hospice language in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS).

Validation surveys return

This year marks the resumption of CMS’ survey validation processes. This includes validation of surveys by accreditation organizations (AO). Beginning March 4, 2020, CMS had temporarily halted validation surveys due to the COVID public health emergency (PHE).

Also in 2024, CMS is implementing direct observation validation surveys (DOVS). Piloted in 2018 – 2019, the DOVS process includes CMS contractor oversight and observation of an AO surveyor as they conduct hospice surveys. CMS has released a Standard Operating Procedure (SOP) delineating the process and has plans to update the State Operations Manual (SOM).

Further details should appear from CMS within the next few months as the agency revises its resources.

DOVS surveys may become part of a new normal in hospice quality oversight, according to Skehan.

Hospices should educate and communicate with staff to ensure that they understand not only survey processes, but how to comply with current standards, Skehan added. One way to achieve this is through mock surveys.

“We have all that oversight in helping us to make sure that we have processes in place that tune in to support [surveyors] approach and their decision making in surveys,” Skehan said. “CMS contractors are going out with the AO surveyors and observing. It’s not a separate survey, it’s not going to be two sets of findings, and they are not conducting the survey. They are observing our site, our surveyors. Very soon, within the next six months, even we will not know when they’re coming. That is fairly frequent, and it’s happening now.”

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