If your organization is facing an onsite recertification survey, a citation, or a decertification notice, timing works against you. We help you respond fast and build a record that holds up.
The Landscape
Team Lead – UNOS & OPO Compliance Consulting
Onsite recertification surveys resumed in summer 2026, with a CMS final rule on OPO Conditions for Coverage anticipated by late 2026. CMS has indicated that recertification and decertification proceedings for Tier 2 and Tier 3 organizations could begin as early as January 2027. Surveyors are now instructed to issue citations for identified deficiencies even after they have been corrected, which means documentation of past problems matters as much as the fix itself.
If CMS moves to terminate an OPO’s agreement for noncompliance, the process typically allows 90 days’ notice, or just 3 days in urgent situations involving serious injury or death risk. An organization may seek reconsideration within 15 business days, and, if denied, request a hearing within 40 business days of that denial. Hearing officers are required to issue a decision within 20 business days.
Every one of those deadlines is procedural, not discretionary — miss the 15-business-day reconsideration window and the option is generally gone. Organizations that come to us after a notice has already been issued are, understandably, focused on the underlying compliance problem. Our first job in that situation is usually just making sure the clock isn’t allowed to run out while the substantive response is still being prepared.
Common Situations We’re Brought In For
Organizations typically reach out to us at one of a few recognizable moments:
- A Tier 2 or Tier 3 classification with a recertification survey approaching and no clear internal owner for the response
- A citation received during a routine survey, with a corrective action plan due on a short deadline
- A decertification notice, with the 15-business-day reconsideration window already running
- A pattern of smaller findings across multiple survey cycles that hasn’t triggered a formal action yet, but signals one is coming
- A leadership or board transition happening at the same time as a scheduled recertification survey
What Happens If This Isn’t Fixed
Under current CMS guidance, corrected deficiencies are still citable, which means the practical consequence of a gap isn’t limited to the moment it’s discovered — it can follow your organization into the next survey cycle as part of a documented pattern. An organization with several small, individually corrected findings across multiple cycles can find itself facing a harder conversation at the next survey than the severity of any single finding would suggest.
The procedural deadlines in a decertification process are equally unforgiving: a missed 15-business-day reconsideration window generally cannot be recovered, regardless of the strength of the underlying compliance argument.
Where We Help
1. Mock Survey & Readiness Assessments
We run a mock survey against current CMS standards — governance, personnel, data reporting, family engagement, hospital agreements, and QAPI — to surface deficiencies your team can fix before a real surveyor arrives, using the same document requests and interview approach a CMS surveyor would use.
2. Corrective Action Plan (CAP) Development
When a deficiency is cited, we help build a corrective action plan that satisfies CMS while creating a durable record of the fix — including the follow-up evidence showing the corrective action actually held over subsequent review periods, not just that a policy was rewritten once.
3. Decertification Appeals & Hearing Representation
If your organization receives a decertification notice, we help prepare and file your reconsideration request within the 15-business-day window and represent your organization through hearing proceedings if the appeal is denied, working alongside your legal counsel throughout.
4. Rapid-Response Crisis Support
For urgent notices with a 3-day response window, or any situation where the clock is already running, we mobilize immediately — prioritizing the procedural deadlines first, then building out the substantive response in parallel, to protect your organization’s standing and reputation.
What an Engagement Looks Like
If you’re preparing proactively, we typically run a full mock survey four to six months ahead of your recertification date, giving your team time to close gaps before the real thing. If you’re responding to an active citation or notice, the engagement starts immediately with the procedural deadlines — reconsideration filings, CAP due dates — while we build out the underlying compliance and documentation response in parallel, so nothing is sacrificed to the clock.
Throughout, we keep your board and executive leadership briefed in plain terms on where things stand procedurally and substantively, since a decertification proceeding is as much a governance and communications challenge as it is a compliance one.
Dr. Smith brings direct experience with this kind of pressure — having led a transplant program’s team through an intensive period of Joint Commission and UNOS investigations and frequent, detailed regulatory reporting, and out the other side to a fully compliant, better-resourced program. She knows firsthand how much of surviving a regulatory review comes down to how well an organization can produce and stand behind its own documentation under scrutiny.
Related UNOS & OPO Compliance Areas
Most compliance gaps don’t stay contained to a single Condition for Coverage — a weak data reporting process usually shows up again in your QAPI reviews, and a thin family-consent record usually shows up again during a CMS survey. We typically look at the following areas together:
- OPO Conditions for Coverage Compliance & Recertification — governance, personnel, performance measures, and Tier classification under 42 CFR Part 486 Subpart G.
- OPTN & SRTR Data Reporting Compliance — data submission timeliness, error correction, and seven-year record retention.
- QAPI Program & Death Record Review Compliance — quality assessment programs and mandatory monthly death record reviews.
- Donor Family Consent & Hospital Agreement Compliance — family engagement documentation, role separation, and hospital agreements.
FAQs
If we’ve had small findings in past surveys that were all corrected, are we still at risk?
Potentially, yes. Under current guidance, corrected findings remain part of your citation history, and a pattern across multiple survey cycles can factor into how CMS and surveyors approach your next review, even though each individual issue was resolved at the time.
We received a decertification notice. What’s our first deadline?
In non-urgent cases you generally have 90 days’ notice before termination, but a request for reconsideration must be filed within 15 business days — that is almost always the deadline that matters most in the near term.
What happens if our reconsideration request is denied?
You may request a hearing before a CMS hearing officer within 40 business days of the denial. The hearing officer is required to issue a decision within 20 business days of the hearing.
Can a deficiency still be cited if we already fixed it before the survey ended?
Under current CMS guidance, yes — surveyors are instructed to cite identified deficiencies regardless of whether they were corrected during the survey. This makes proactive readiness assessments far more valuable than in-survey fixes.
How soon can you get involved after a citation or notice is issued?
Given the short deadlines involved, particularly the 15-business-day reconsideration window, we prioritize an immediate initial response and can typically begin within days.
Do you replace our legal counsel in a decertification appeal, or work alongside them?
We work alongside your legal counsel. Our role is the compliance and regulatory substance of the appeal — the record, the corrective evidence, the CAP — while your attorneys handle the legal proceeding itself.
What does a mock survey actually involve?
The same document requests, interviews, and review approach a real CMS surveyor would use, covering governance, personnel, data reporting, family engagement documentation, hospital agreements, and QAPI, with a findings report scoped and prioritized the same way an actual citation would be.
Is it too late to prepare if our survey is only a few weeks away?
It’s not ideal, but it’s rarely too late to matter. Even a compressed readiness review in the weeks before a survey typically identifies the highest-risk gaps — the ones most likely to be cited — so your team can address what’s fixable in the time available.