On January 13, 2020, the Centers for Medicare & Medicaid Services (CMS) announced a new streamlined survey and certification process for psychiatric hospitals as part of the agency’s “Patients over Paperwork” initiative. According to CMS, this new survey process will ensure safety and quality through more holistic and efficient hospital inspections that protect patients, while reducing the burden for providers.
Under the new process, psychiatric hospitals surveyed by State Survey Agencies (SSAs) will no longer be subject to two separate onsite compliance surveys as they are currently (one by the SSA for compliance with the hospital requirements and one by an outside contractor selected by the SSA for compliance with two additional psychiatric hospital standards).
Beginning March 2020, psychiatric hospitals will receive one comprehensive hospital survey performed by the SSA to review compliance with both hospital and psychiatric hospital participation requirements, allowing inspectors to take a broader view of a psychiatric hospital’s operations and better identify systemic quality issues.
Psychiatric hospitals that participate in Medicare are required to meet both general Medicare hospital Conditions of Participation (CoPs) and separate psychiatric hospital CoPs, which promote the health, safety and well-being of the patients being treated in these facilities under the new survey process. CMS is not making any changes to these safety and quality requirements.
CMS believes that moving to a single survey process will benefit patients by ensuring psychiatric hospital services are evaluated in the context of the overall hospital survey program. It also believes this will make it easier for surveyors and the provider to identify and correct systemic quality issues that impact patient care. Additionally, CMS believes this new process will benefit providers by reducing the regulatory burden currently imposed on psychiatric hospitals, because a single survey team will conduct the survey, and only one report would be issued documenting any survey findings, instead of two.
The change in the survey process does not affect accreditation organizations’ current methodologies for approving hospitals or psychiatric hospitals or CMS’ criteria for approving accreditation organizations to survey such facilities. To ensure states are appropriately prepared to begin conducting these surveys in March 2020, CMS is developing an online training that will be released soon. The full CMS memorandum, released January 13, 2020, with more information about the change in the psychiatric hospital survey process can be found here.
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