CIHQ Earns CMS Approval as an AO For Next 5 Years

‐

By A.J. Plunkett

The Center for Improvement in Healthcare Quality (CIHQ) has been approved by CMS as a hospital accrediting organization (AO) for another five years, effective January 1, 2023 through January 1, 2028.

As part of the approval process, CIHQ has made several changes and will likely make more as required by CMS. The changes largely involve standards and procedures related to fire safety and facilities management standards and surveys.

Among the updates made already, according to the public notice set to be published in the Federal Register on December 19:

  • Life Safety Code® (LSC) references have been included in standards to address hospitals classified as new occupancies and requirements added for hospitals classified as business occupancies
  • Standards now reference the 2008 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) “Standard 170—Ventilation of Health Care Facilities,” in accordance with 2012 NFPA requirements and “to ensure sterile supply and medical equipment manufacturer instructions for use (IFU) are considered before hospitals reduce relative humidity levels
  • Revised CIHQ’s Facility & Life Safety worksheets for surveyors to explain that the “worksheet does not include all 2012 LSC & Health Care Facilities Code requirements in accordance with survey comparability” at Condition of Participation (CoP) §488.5(a)(4)(ii)
  • Have or will be providing additional training to surveyors related to the number of medical records that should be reviewed during the survey of larger hospitals “in accordance with survey comparability at §488.5(a)(4)(ii)”
  • Improved the level of detail required in survey documentation
  • Revises complaint procedures to ensure the survey investigation process is clearly documented “in accordance with the organizations complaint procedures at §488.5(a)(12)”

Because of continuing restraints related to the COVID-19 pandemic, CMS said it could not conduct a review of a CIHQ survey as required but did note that the AO has also applied for approval of a critical access hospital Medicare deeming program.

“Critical access hospitals have similar CoPs and survey process to hospitals and therefore we are confident in a 5-year approval term for this application,” according to the CMS notice.

A.J. Plunkett is editor of Inside Accreditation & Quality, an HCPro publication.