EC MiSHE Chapter Article - March 2025

The memo specifies the roles of state and federal agencies versus accrediting organizations when facilities temporarily lose their Medicare-deemed status May 4, 2026 | Leah Hummel On March 25, the Centers for Medicare & Medicaid Services (CMS) issued revised memo QSO-18-12-Deemed Providers/Suppliers to clarify the roles of accrediting organizations (AOs) and state survey agencies (SAs) when a provider’s or supplier’s Medicare-deemed status is temporarily removed due to condition-level noncompliance. CMS may temporarily remove deemed status when an SA or federal survey team identifies condition-level deficiencies. When this occurs, the CMS location formally notifies the organization and places it under the jurisdiction of the state survey agency, rather than the AO. The revised memo reinforces that accrediting organizations must suspend or postpone Medicare deeming recertification surveys while deemed status is removed. Importantly, CMS clarifies that if a provider’s regular 36-month accreditation cycle lapses during this period, the AO will not be cited as late or noncompliant for missing the survey. CMS also notes that while non-deeming accreditation surveys are not prohibited during state oversight, CMS recommends postponing these activities to avoid confusion or duplication while the organization works toward regaining compliance. The revised guidance also provides additional clarification on complaint investigations, emphasizing the need for coordination between SAs and AOs. During temporary removal of deemed status, the SA maintains primary responsibility for investigating complaints, while keeping the AO appropriately informed. Why this matters for facilities For hospitals and health systems, including facilities and physical environment leaders, the memo underscores the importance of understanding who has regulatory authority during periods of noncompliance. While temporary loss of deemed status due to a state survey agency or federal team survey does shift oversight of follow-up activities it does not penalize organizations or their AOs for unavoidable survey delays while corrective actions are underway. Leah Hummel, AIA, CHFM, SASHE, CHC, CHOP, is senior associate director of ASHE Regulatory Affairs 

In the June 3, 2026 article by Matthew Daniel in Health Facilities Management, entitled Are Joint Commission environment of care management plans still required?, Matt explains many good reasons why facilities should consider keeping their management plans even though since January 2026, they are no longer required (except for ambulatory care). He explains that “while the formatting of its standards would change, JC made it clear that the requirements themselves would not and that hospitals and CAHs should not make changes to their existing programs since they are still held to CMS’s requirements.” “In its January 2026 issue of Environment of Care News, JC stated that hospitals and CAHs are no longer required to have environment of care management plans for each of the … physical environment areas. The newsletter stated that “except for ambulatory care organizations, Joint Commission no longer requires a written management plan or separate plans addressing each of the physical environment functional areas: safety, security, hazardous materials and waste, utilities, and medical equipment.” JC further clarified that the only management plans that will be evaluated during a survey will be the organization’s fire response plan, water management plan and emergency operations plan.” Mr. Daniel gives many good reasons for keeping elements of the management plans including the fact that “ the management plans are used by organizations to not only provide a roadmap to all of the required aspects of the standards for each respective plan but also to ensure that any supporting policies or procedures also are incorporated into the program — whether it’s an internal policy or procedure or a requirement of the accreditation process.” He concludes his article by stating, “While the requirement for environment of care management plans is not contained in JC’s new Physical Environment Chapter for hospitals and CAHs, the foundation of organizational compliance within the physical environment is still required, and continuing the process of evaluating and updating these management plans provides a path to help ensure continuous compliance.”  For a copy of the full article see Matthew Daniel . Matthew Daniel, CHSP, is a senior consultant at Daniel Consulting LTD. He can be reached at matthew.daniel@danielconsulting.net.