Full speed ahead: CMS resumes most surveys


April 1, 2021

by A.J. Plunkett (aplunkett@decisionhealth.com)

CMS surveyors could be on your doorstep tomorrow if you have faced a complaint in the last two months that did not involve an immediate jeopardy (IJ) to patients, staff or visitors.

Effective now, CMS surveyors are resuming hospital surveys on the limited basis as set out in a Quality, Safety & Oversight Group memo last August. Up first are uninvestigated complaints, with a target survey within 45 days.

Since January 20, CMS state surveyors were only investigating serious patient safety issues that potentially put patients, staff or visitors in immediate jeopardy (IJ), as outlined in QSO-21-13-Hospitals. Most other surveys were on hold as CMS evaluated the continuing impact of the COVID-19 pandemic.

The newest memo on surveys — QSO-21-16-Hospitals, “Resuming Hospital Survey Activities Following 30-day Restrictions”— was posted online March 26 but carried an effective date of March 23. In it, CMS also told state survey agencies that hospital complaints that did not involve an IJ should be investigated within 45 days.

Kurt Patton, MS, RPh, founder of Patton Healthcare Con­sulting and former director of accreditation services with TJC, said the memo was pretty straight-forward, but that hospitals should particularly take note of two deadlines.

The first is the 45-day window for CMS surveyors to catch up on non-IJ hospital complaints, says Patton. In addition, hospitals should be prepared to submit plans of correction (POC) within 10 days of March 23, which is April 2.

However, if your facility is in the middle of a COVID-19 surge, there is some flexibility.

According to the CMS memo, “All open surveys with cited deficiency tags must have an acceptable POC and supporting evidence in order for the tags to be corrected. Providers have 10 calendar days from the effective date of this guidance to submit their POC for surveys that ended on or after January 20, 2021.”

In a note that follows, CMS said, “Providers who may have difficulty allocating resources to develop and implement a POC because they are currently experiencing an outbreak of COVID-19 in their area should contact their SA and/or CMS location to request an extension on submitting a POC.”

“Onsite revisits are authorized and should resume as appropriate,” according to the memo.

The January memo temporarily suspending all but major CMS surveys was effective for 30 days, with 30-day renewal notices. That last renewal was up March 22.

Read the full three-page memo on resumption of surveys www.cms.gov/files/document/qso-21-16-hospitals.pdf.


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