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Summary Survey Report – Due September 20, 2012

PDF Version of DQA 12-010  (PDF, 203 KB)

Date: July 24, 2012 -- DQA Memo 12-010
To: Hospitals HOSP 02
From: Cremear Mims, Director
Bureau of Health Services

Otis Woods, Administrator
Division of Quality Assurance

Summary Survey Report – Due September 20, 2012

The purpose of this memo is to request hospitals that are accredited and deemed to meet the federal conditions of participation submit a copy of the Summary Survey Report. The report from the Accrediting Organization (AO) includes the regulatory requirements that the AO found to be in non-compliance, the findings that substantiate these deficiencies and the final letter of accreditation/deemed status.

The Department of Health Services (DHS), Division of Quality Assurance (DQA) is requesting hospitals to submit this report by September 20, 2012, and annually thereafter along with the “Hospital’s Annual Report”.


The Division of Quality Assurance (DQA) is responsible for conducting Wisconsin Licensure hospital surveys along with federal certification surveys. Currently, DQA conducts licensure surveys simultaneously with the federal surveys to maximize resources and limit interruptions to providers. However, many years have passed since some licensure surveys were conducted in accredited/deemed facilities; therefore, DQA will review the Summary Survey Reports as a State Licensure monitoring tool.

Review of these reports is not a substitute for federally authorized surveys or complaint investigations.

Wisconsin Statues 50.36 (3m) indicates: “The department shall require a hospital that is accredited as a hospital by a private accrediting organization to submit to the department a copy of the summary accreditation recommendation and may require the hospital to submit to the department copies of all correspondence sent or received on or after August 30, 1989, including survey results, between the hospital and the accrediting organization. Accreditation letters, reports and related correspondence submitted to the department, except those submitted by a county mental health complex under s. 51.08, under this subsection are not subject to inspection, copying or receipt under s. 19.35 (1) and may not be released by the department”.

As a means of conserving resources, monitoring compliance and limiting provider business interruptions, the Division of Quality Assurance is requesting the “Summary Survey Report” as allowed by the above Wisconsin State Statutes, Chapter 50.

Please submit your report to:

Tracy Ellingson, Human Services Program Coordinator 
P.O. Box 2969, Room 1151
Madison, WI 53701-2969

If you have any questions about this request, please contact Tracy at (608) 266-7297 or

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Last Updated: July 25, 2012