Facility reported incidents final report: interpretation change

The Centers for Medicare and Medicaid Services (CMS) has provided guidance that CMS now interprets the “ within 5 working days” of final reports from facilities as “business days, which excludes Saturday, Sunday, and Federal holidays.”

§483.12(c): In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

4. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.”

As a result of this interpretation, facilities will no longer be required to submit their final report on Saturdays, Sundays, or Federal holidays. These days will be excluded from the 5-day timeframe for final reports.

With this change, the South Dakota Department of Health Office of Licensure and Certification would like to provide some helpful information and suggestions:

1. The complaint department triages facility reported incidents based on the information provided by the facility. Triage criteria is based on SOM Chapter 5 and also takes into consideration the respective provider appendices.
2. Please provide a thorough summary of interventions you have put in place to protect residents/patients and staff (if applicable). The more information, the better.
3. If it is determined that an onsite complaint survey is required, SOM Chapter 5 requires surveyors to be onsite within a designated timeframe from the date of the initial report from the facility (there are some caveats to this). With the change noted above, if the provider has additional information that could assist with the triage of your FRI and it is prior to day 5, the provider may edit their initial report to include additional information. Additional information may assist with lowering triage levels. For example, immediate jeopardy triage requires entry within 2 to 7 business days from the facility’s initial report depending on the situation and provider type. However, if adequate information is provided, triage may be lowered which allows entry into the facility at a later date (if an onsite survey is required).
4. If you have questions, please contact the complaints department at doholccomplaint@state.sd.us.