AOs process changes amid accreditation’s new normal

YARMOUTH, Maine – Accrediting organizations (AOs) have some breathing room thanks to a decision by the Centers for Medicare & Medicaid Services (CMS) to phase in its new policy requiring annual resurvey and reaccreditation for DMEPOS providers. 

In a provision summary following a Nov. 28 final rule, CMS clarified that a provider’s annual resurvey and reaccreditation cycle will not begin until the expiration of its current three-year cycle, if issued prior to Jan. 1, 2026, the start date of the new policy. 

“It’s nice that it’s essentially being phased in,” said Rhonda Pearce, executive director of the Healthcare Quality Association on Accreditation (HQAA). “That gives us the time to ramp up so that it’s not going to really hit us until after 2027. It will start to get busier and busier, but it won’t be crazy until 2028. That’s helpful.” 

In late December, HQAA was working internally to update its systems to reflect the new policy. 

Impact on staffing and surveyor training 

With resurvey and reaccreditation every year instead of every three years, AOs will need to hire more surveyors – a process that takes time, Pearce says. HQAA’s process for onboarding new surveyors includes training them and then pairing them with an experienced surveyor to first shadow a survey, then participate in a survey, and finally conduct a survey independently, she says 

“We make sure they’re qualified, and able to survey and follow all of CMS guidances,” she said. 

The Compliance Team (TCT) also expects to hire additional surveyors but doesn’t have a “sense of urgency,” says Sandy Canally, founder and CEO. Most of its surveyors are full-time employees who, when they’re not in the field conducting surveys, are doing a variety of other tasks, like following up with providers and educating them, she says. 

“Because we have so many other programs (outside of DMEPOS), we’ve hired along the way,” she said. “We are in good shape to get this started.” 

The Community Health Accreditation Partner (CHAP) is actively hiring more site visitors “to ensure that our timely survey window stays fast,” says Dan McPhilemy, senior vice president of marketing. 

Data reporting and corrective action plans 

While the annual resurvey and reaccreditation requirement has grabbed headlines, the new policy also requires additional data reporting by AOs – an area where TCT plans to make a more immediate hire, Canally says. 

“I look at this as our machine that keeps everything going, with everything else being a support structure,” she said. “So right now, that’s who we’re going to be seeking to hire to help with that data reporting.” 

Much of that data reporting will revolve around corrective action plans (CAPs) – a process that the new policy makes more structured, Canally says. Providers, for example, now need to submit evidence when they submit their CAPs to AOs. 

“It can’t just be, we’ve developed a policy, or we’ve done this training,” she said. “We’re going to need proof that they’ve made an implementation and a correction. It will be more challenging.” 

The process will also be more timely, Canally says, with CMS requiring AOs to then submit CAPs to CMS within a certain number of days. “There will be a lot of work; a lot of back and forth,” she says. 

A shift toward continuous quality improvement 

Bigger picture, the new policy positions accreditation as a continual process rather than a once-every-three-years event. When Canally started TCT, she designed its program around annual visits. 

“This is actually going back to our roots,” she said. “It basically means that you treat it as a measured continuous quality improvement program and when you focus on that, that’s a different message than, ‘OMG we have to train people last minute because we’re going to have a survey in the next couple of months.’” 

While daunting, Pearce also says the new policy gives a clearer picture of CMS’s expectations and what happens if they’re not met. 

“There can be a lot of gray areas, so I think some good can come of this,” she said.