AHA Special Bulletin
March 26, 2021
Survey activities’ resumption is retroactive to March 23, 2021
The Centers for Medicare & Medicaid Services today announced the immediate resumption of survey activities for all complaints.
On Jan. 20, 2021, CMS issued guidance limiting hospital surveys for all complaints other than Immediate Jeopardy (IJ) complaints. The suspension period lasted for 30 days and was extended once, keeping the suspension in place through March 22, 2021.
In the newly release guidance, CMS states that it is not extending the survey suspension beyond the March 22, 2021 date.
A summary of the announcement follows.
SUMMARY OF SURVEY RESUMPTION GUIDANCE
As of March 23, 2021, survey activity may resume in accordance with the Non-Long Term Care Guidance found in QSO 20-35-All.
Hospital Non-IJ Complaints. Any non-IJ complaints received during the hospital survey suspension must be investigated within 45 days of the March 23, 2021 effective date.
Hospital Plans of Correction. As a byproduct of the survey suspension period, hospitals were permitted to delay Plan of Correction (POC) submissions until the suspension was lifted. Now that the suspension is no longer in place, providers must submit any delayed POCs within 10 days of March 23, 2021 for any surveys that ended on or after Jan. 20, 2021.
NOTE: If your hospital or health care system is still experiencing a COVID-19 surge that will make the development and implementation of a POC difficult, you should contact your state agency or CMS location to request an extension.
Hospital Desk Reviews. State surveyors are permitted to perform desk reviews of all open surveys that cited any level of noncompliance, including IJ complaints in which the IJ finding was removed or moved to a lower level of non-compliance. This applies only to outstanding enforcement actions held during the survey suspension. In instances in which an IJ finding existed and was not removed, surveyors are required to conduct an onsite revisit.
Hospital Revisit Surveys. All onsite revisits are authorized and should resume. Further, in order to perform a desk review, state agencies must request that facilities submit evidence supporting correction of noncompliance, which can include evidence of training, staff attendance and staff competency evaluations. In those instances where a desk review is performed, state agencies will have discretion to include the specific clinical area of concern in the next onsite survey.
Open Hospital Enforcement Activities. Hospitals with open enforcement actions not constituting IJ will have at least 60 days, and up to 90, to demonstrate compliance with any outstanding non-IJ deficiencies.
- Please share this document with your leadership team, as well as quality and patient safety personnel.
- If your organization is unable to develop and implement a POC due to a COVID-19 surge, please notify Nancy Foster (firstname.lastname@example.org) or Mark Howell (email@example.com), as well as your state agency and/or CMS location.
If you have questions, please contact AHA at 800-424-4301.