April 07, 2021 – The Centers for Medicare & Medicaid Services has announced the immediate resumption of all hospital survey activities, including those related to Medicare compliance and patient safety.
This comes after the agency hit pause on the surveys while hospitals worked to mitigate the COVID-19 crisis.
On January 20, CMS issued QSO-21-13-Hospitals, which established a 30-day suspension period limiting hospital surveys to immediate jeopardy complaints, such as allegations that pose patient safety concerns and Medicare noncompliance with hospital conditions of participation.
Hospital enforcement actions for shortcomings that did not present immediate jeopardy had their termination date extended for at least 30 days. CMS also suspended hospital recertification surveys, except for a subgroup of hospital reaccreditation surveys based on guidance provided to the accrediting organizations.
As COVID-19 infections climbed at the beginning of the year, CMS suspended of non-immediate jeopardy hospital survey complaints to allow hospitals to focus on providing their patients and communities with high-quality care.
The suspension period was extended once, pushing the policy’s effect through to March 22, 2021. However, in the newly released guidance, CMS states that it has not extended the survey suspension beyond March 22, 2021. Survey activity will resume in accord with the non-long term care guidance issued in QSO20-35-All.
Now that COVID-19 cases are on the decline, non-immediate jeopardy hospital complaints that were received during the survey suspension period will be investigated within 45 days of date of the announcement released on March 26.
CMS also noted that desk reviews will be permitted for open surveys cited at any level of noncompliance. However, unremoved immediate jeopardy findings will require an onsite revisit. With this most recent announcement, CMS authorizes onsite revisits that will resume as appropriate.
Additionally, open enforcement cases that are not considered immediate jeopardy will have between 60 and 90 days to show compliance with outstanding deficiencies.
Hospital Plans of Correction (POCs) will be required for all hospital shortcomings cited on surveys conducted on or after January 20, 2021, including Medicare compliance deficiencies. In addition, hospitals that were permitted to delay their submission of required POCs must now submit the POC by April 5, which is 10 calendar days following issuance of the CMS’ survey memorandum.
All open surveys with cited deficiency tags must have an acceptable POC with supporting evidence for said tags to be removed.
Usually, hospitals must submit POCs within 10 calendar days after receiving the statement of deficiencies (Form CMS-2567). This brief timeline gives surveyors time to review a POC and determine if it is acceptable. Then, the surveyors can perform revisit surveys within 45 calendar days (prior to the tentative termination date).
While QSO-21-13-Hospitals extended this timeline by pushing the start date to when regular surveying began again, a law group cautions that the policy may vary by CMS Regional Office or State Survey Agency. Therefore, it is important for hospitals not to assume they have an extended response period, as federal and state instructions may vary.
CMS also noted that if a hospital believes it cannot meet the POC deadline because it is currently experiencing an outbreak of COVID-19 in its geographic area, the hospital should contact the State Survey Agency and/or CMS location to request an extension.