Hospital Surveys by the Centers for Medicare and Medicaid Services: An Analysis of More Than 34,000 Deficiencies

Abstract

Objectives: The aims of the study were to analyze hospital deficiencies reported by the Centers for Medicare and Medicaid Services (CMS) for a 10-year period (2007-2017) and thereby determine the specific conditions of participation (CoP) cited in each deficiency.

Methods: Deficiency data from the CMS Web site was downloaded and analyzed. A determination was made regarding the CoP assigned to each deficiency. In addition, deficiencies were analyzed according to the presence or absence of an immediate jeopardy (the most serious potential risk) and whether there was state-to-state variation.

Results: A total of 30,808 of 34,522 deficiencies were assigned specific "tags" related to a COP, with 77% of the A tags assigned to the following six CoP: patient rights, nursing services, quality improvement, medical records, governing body, and emergency services. Immediate jeopardy was assigned in 730 tags, and a patient death was more likely to be associated with the determination of immediate jeopardy; actual patient deaths were associated with 21% of surveys that resulted in immediate jeopardy. Survey rates varied state-to-state; 14.3 surveys per 1 million population at the 80th percentile and 6.0 surveys per million at the 20th percentile, respectively. Utah and Vermont had the least (1.7) and greatest (70.3) rates, respectively, a 41-fold difference.

Conclusions: These data indicate that (a) hospital surveys result in most deficiencies being assigned to a subset of CoP; (b) a patient death is more likely to be associated with a finding of immediate jeopardy, and (c) there is significant state-to-state variation in survey rates.