CMS memo: Hospitals to be surveyed on new requirements starting in November


Subject Matter: Article | Topics: Codes and standards

The Centers for Medicare & Medicaid Services (CMS) issued a memo this week stating it will begin surveying hospitals for compliance with its new Conditions of Participation (CoPs) starting Nov. 1. Health care facilities will be surveyed under existing regulations until then.

ASHE had previously alerted members of a Joint Commission memo that said health care facilities would have until November to prepare for the new regulations. The CMS memo explains that the effective date of the new regulations is July 5 as stated in the agency’s federal rule, but also confirms that surveyors will not look for compliance with the updated requirements until Nov. 1.

From now until Nov. 1, in instances where the survey process identifies deficiencies that would be compliant under the 2012 edition of the Life Safety Code®, facilities may verify compliance with the 2012 edition as an acceptable plan of correction, and the deficiency would not be cited.

The CMS memo also provides additional details on training CMS will provide for Life Safety Code surveyors. And CMS noted in the memo that its Automated Survey Processing Environment (ASPEN) software would be updated with the new regulation sets correlating with the 2012 editions of NFPA 101, NFPA 99, and associated K-tags.

CMS adopted new CoPs in May that adopt the 2012 editions of NFPA 101 and much of NFPA 99. ASHE has multiple resources available for members, including a webinar series and On Demand recordings of previous webinars detailing the changes. View resources at