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Download all Substantial Deficiencies in Excel

List of CMS-Certified Hospitals with Recent Substantial Deficient Practice


Hospitals participating in Medicare and Medicaid receive onsite surveys by State Survey Agencies and private Accrediting Organizations to ensure compliance with Federal Regulations. When the survey agency or Accredication Organization finds a hospital not to be in compliance, it cites a deficiency and issues a survey report that summarizes the findings.

This website lists all hospitals who were found to be substantially out of compliance during a State Survey Agency survey in the last six months and provides the survey report for public review.

To locate a hospital, begin by selecting to see a list of hospitals by state or by Accrediting Organization to the left.

Medicare Oversight of Accrediting Organizations


To ensure private Accrediting Organization provide a sufficient level of oversight, Medicare conducts Validation Surveys by conducting a survey of a hospital shortly after an Accrediting Organization completes a survey. In addition Medicare submits an annual Report to Congress on the effectiveness of Accrediting Organizations.
The below table gives a brief overview of how many Validation Surveys were conducted for the last few Federal Fiscal Years and the disparity between the Medicare conducted surveys, and the private Accrediting Organization Surveys.
You can find the latest Report to Congress here


60-Day Validation Survey Results for Each Facility Type Fiscal Years (FYs) 20142016
  FY 2014 FY 2015 FY 2016
Hospital
60-Day Validation Sample Surveys 103 102 98
SA Surveys with Condition-Level Deficiencies 41 42 50
AO Surveys with Missed Comparable Deficiencies 39 40 45
Disparity Rate 38% 39% 46%
Sampling Fraction 0.09 0.08 0.07
Psychiatric Hospital
60-Day Validation Sample Surveys 12 16 21
SA Surveys with Condition-Level Deficiencies 10 12 12
AO Surveys with Missed Comparable Deficiencies 9 11 12
Disparity Rate 75% 69% 57%
Sampling Fraction 0.08 0.1 0.11
Critical Access Hospital
60-Day Validation Sample Surveys 27 33 34
SA Surveys with Condition-Level Deficiencies 16 15 16
AO Surveys with Missed Comparable Deficiencies 14 15 15
Disparity Rate 52% 45% 44%
Sampling Fraction 0.17 0.18 0.24

Last updated on 07/12/2019 with all surveys since 01/01/2019