Hospitals: Be Ready for the CMS Survey

COVID-19’s impact on the survey process was profound. On January 20, 2021, CMS limited hospital surveys for 30 days. Only certain types of surveys would continue, including complaint surveys involving immediate jeopardy (IJ) and certain noncompliance with Medicare Hospital Conditions of Participation requiring immediate action to protect patient health and safety. Most hospital recertification surveys were also suspended. In addition, CMS extended the termination date by at least 30 days for hospital enforcement actions where deficiencies did not represent IJ. On February 18, 2021, CMS extended these limitations for an additional 30 days until March 22, 2021. (See guidance here).

Now CMS has issued new guidance, lifting the 30-day limitations for hospital surveys as of March 23, 2021. State survey agencies may now resume surveys in accordance with prior guidance issued in August 2020. Specifically:

• Hospital Non-IJ Complaints – Complaint surveys triaged as non-IJ high, which were received during the survey suspension, must be investigated within 45 days from March 26, 2020.
• Hospital Plans of Correction – Hospitals were permitted to delay the submission of a Plan of Correction until the survey suspension period ended. Providers now have 10 calendar days from March 26, 2021, to submit their Plans of Correction for surveys that ended on or after January 20, 2021. (CMS noted that hospitals having difficulty allocating resources to develop and implement a Plan of Correction because they are currently experiencing an outbreak of COVID-19 should contact their state agency or CMS to request an extension.)
• Hospital Desk Reviews – State surveyors may perform desk reviews for some open surveys for enforcement actions that were held from January 20, 2021 through March 22, 2021. Unremoved IJs will require an onsite revisit, however.
• Hospital Revisit Surveys – Beginning March 23, 2021, all onsite revisits are authorized and should resume, as appropriate, per the Medicare State Operations Manual (SOM).
• Open Hospital Enforcement Actions – Hospitals with open enforcement actions that do not constitute IJ will have at 60 to 90 days to demonstrate compliance with outstanding deficiencies that are not IJ.

Based on this new CMS guidance, hospitals should turn their attention to continued compliance with Medicare Conditions of Participation, in anticipation of increased survey activity. Arent Fox has a large, robust group of healthcare attorneys with deep experience in advising hospitals in survey and certification matters, including Medicare termination actions.