CMS Releases Top Citations from 2023

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CMS Releases Top Citations from 2023

Reviewing common cited areas can help ASCs improve outcomes

The Centers for Medicare & Medicaid Services’ (CMS) Quality, Certification & Oversight Reports (QCOR) page allows the public to pull citation frequency reports for both health surveys and Life Safety Code surveys. However, due to systems migrations, CMS has not been able to update the data since May 2022. ASCA obtained 2023 figures from CMS staff who pulled the following information for ASCA on May 30, 2024. ASCA expects the QCOR page to be updated soon to allow the general public to access this information directly.

The 2023 survey data includes citations given during 3,023 ASC surveys. The number of surveys is higher than in years past because it includes information from state agencies and deemed status survey data from accrediting organizations. While you can drill down on specific facilities to see which tags they were cited for, unfortunately, information on the specific cause of the citation within each tag is not available.

CMS Health Surveys

Infection control remains a focus of CMS surveyors, as seen by three of the top 10 health survey citations falling under infection control and the top two most cited tags falling under the infection control Condition for Coverage. Review the Infection Control Surveyor Worksheet to help avoid these citations.

Tags are listed from most frequently to least frequently cited, with the number of citations in parentheses.

  • Q0241 Sanitary Environment (507)
  • Q0242 Infection Control Program (372)
  • Q0100 Environment (316)
  • Q0181 Administration of Drugs (272)
  • Q0240 Infection Control (154)
  • Q0101 Physical Environment (154)
  • Q0162 Form and Content of Record (141)
  • Q0040 Governing Body and Management (117)
  • Q0122 Reappraisals (102)
  • Q0221 Notice of Rights (93)

The Reappraisals tag, cited in 3 percent of surveys in 2023, was new to the top 10 list. The Notice of Rights tag also was not on the list during ASCA’s last report on citations; it was cited in approximately 3 percent of surveys in 2023. Consult Appendix L of the State Operations Manual, also referred to as the Interpretive Guidelines, for additional details on the regulatory requirements associated with each tag.

Life Safety Code Surveys

During Life Safety Code surveys, the following areas were cited most often, in order of volume of citations.

  • Q0108 Building Safety (339)
  • K0918 Electrical Systems – Essential Electric System (181)
  • K0353 Sprinkler System – Maintenance and Testing (154)
  • K0345 Fire Alarm System – Testing and Maintenance (143)
  • K0712 Fire Drills (123)
  • K0291 Emergency Lighting (110)
  • K0761 Maintenance, Inspection and Testing – Doors (109)
  • Q0104 Safety from Fire (92)
  • K0914 Electrical Systems – Maintenance and Testing (85)
  • K0131 Multiple Occupancies (70)
  • K0293 Exit Signage (64)

For more information on Life Safety Code surveys, please consult Appendix I of the State Operations Manual.