CMS Resumes Survey Activity

On August 17, 2020 CMS released a memo, QSO-20-35-ALL, describing expansion of survey activity and new guidance around enforcement.

This survey expansion is effective immediately for all nursing homes, home health, and hospice providers. 

Survey Activity Triage

June 1:

  • Recertification surveys for special focus facilities & special focus facility candidates.
  • Recertification surveys for facilities who have not had a standard survey in 15 months.
  • Revisit surveys for those who have IJ tags removed but are still out of compliance.

August 17:

  • Complaint investigations triaged as immediate jeopardy (IJ), non-IJ-high, and non-IJ-medium (new).
  • All onsite revisit surveys specified in the State Operations Manual (SOM), Chapter 7.
  • All annual recertification surveys
  • Annual recertification surveys are to be completed within 15-months from the last recertification survey.

Plans of Correction

Providers were allowed to delay submission of their plan of correction when survey activities were suspended in March 2020. It is now time for all providers to submit plans of correction. The QSO memo includes instructions on how to submit those plans of correction. Plans of correction for surveys occurring between March 23, 2020 and May 1, 2020 must be submitted within 10 calendar days. With the increase in submission for these plans of correction, desk reviews are expanded. Desk reviews will be permitted for all citations except for IJ citations that have not been removed or reduced in severity. For IJs that have not been removed or reduced in severity, an on-site survey visit will be required. State agencies will be allowed to add any areas of clinical concern that were cleared on a desk review to the next on-site survey.  All survey citations issued after June 1 will require a plan of correction to be filed via the normal and usual process.

Surveys & COVID

Infection control surveys will continue. Additionally, strike team visits will continue on top of the resumed survey activity. If a provider is having difficulty implementing a survey plan of correction because of COVID-19, please contact the MDH Health Regulation Division survey supervisor listed on your statement of deficiencies or the general number is 651-201-4101.

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