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CMS Issues Guidance Resuming Hospital Survey Activities

CMS is lifting hospital surveys limitations as of March 23, 2021. CMS initially limited hospital surveys to immediate jeopardy complaint allegations for a period of 30 days beginning January 20, 2021 and extended the limitation for another 30 days until March 22, 2021. State Survey Agencies (SAs) may resume survey activity in accordance with the Non-Long Term Care Guidance in ​QSO 20-35-All.

Hospital Non-Immediate Jeopardy (IJ) Complaints
Complaint surveys triaged as non-IJ high received during the hospital survey suspension must be investigated within 45 days from March 26, 2021.

Hospital Plans of Correction (POCs)
Under QSO 21-13 Hospitals memorandum, hospital enforcement actions were held, and providers were permitted to delay the submission of a POC until the survey suspension period ended. 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 March 26, 2021 to submit their POC for surveys that ended on or after January 20, 2021.

Hospital Desk Reviews
State surveyors can perform desk reviews of all open surveys that cited any level of noncompliance, including noncompliance that was cited at the IJ level when the IJ finding has been verified as removed or moved to a lower level of noncompliance. The only exception to the expanded offsite review policy is for unremoved IJs, which require an onsite revisit. This expanded desk review policy applies only to outstanding enforcement actions which were held per QSO 21-13 Hospitals memorandum, from January 20, 2021 through March 22, 2021.

Hospital Revisit Surveys
Beginning March 23, 2021, all onsite revisits are authorized and should resume, as appropriate, per Chapter 2, Section 2732, of the State Operations Manual (SOM). SAs must request facilities to submit evidence that supports correction of noncompliance so that a desk review can be performed based on the latest compliance date on the POC.

Open Hospital Enforcement Actions
Hospitals with open enforcement actions that do not constitute immediate jeopardy will have at least 60 and up to 90 days to demonstrate compliance with any outstanding non-IJ deficiencies.

More information about the resumption of state hospital surveys is available on the here.

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