Breaking Compliance News Blog


Posted by Margaret Scavotto, JD, CHC on 8/18/20 11:52 AM

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In March, CMS announced that it was suspending routine surveys for nursing homes during the pandemic, in order to focus on infection control and Immediate Jeopardy issues. However, CMS announced on Monday that this suspension is coming to an end.

In its memo to State Survey Agency Directors, titled: Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, CMS announced that it is resuming onsite revisits and other surveys, and expanding its desk review.

In addition to the expanded surveys previously authorized for states entering Phase 3 of the Nursing Homes Reopening guidance, CMS is authorizing further survey expansion. The guidance states (direct quote):

… States should resume performing the following surveys as soon as they have the resources (e.g., staff and/or Personal Protective Equipment) to do so:

    • Onsite revisits as specified in the revisit policy in the State Operations Manual (SOM) Chapter 7, Section 7317.2, for surveys with end dates on, or after June 1, 2020;
    • Complaint investigations that are triaged as Non-Immediate Jeopardy Medium; and
    • Annual recertification surveys required to be conducted within 15 months from a provider’s last recertification survey.

The CMS guidance also explains that enforcement actions that were held during the first few months of the pandemic will now move forward to conclusion.

Now is the time to get your Phase 3 compliance programs ready

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CMS’ Monday memo did not tell us when the Phase 3 Final Rule addressing nursing home compliance and ethics requirements will be issued – nor did it tell us when the survey guidance for nursing home compliance and ethics programs will be published. But we know these items are overdue, and CMS appears to be getting back to business as usual. That makes one thing clear: nursing homes need to get ready to be surveyed on their compliance programs.

Compliance efforts were put on hold by many providers when COVID-19 hit. If your organization is not ready to be surveyed on compliance, now is the time to get ready. Here is what you need:

  • Written standards, policies and procedures
  • Assignment of responsibility to high-level personnel
  • Sufficient resources and authority
  • Due care not to delegate to those with a propensity to commit crimes
  • Policy communication to staff, contractors and volunteers
  • Auditing and monitoring
  • Reporting system
  • Disciplinary enforcement
  • Corrective action
  • Annual review

Chains of 5+ SNFs also need:

  • Mandatory annual compliance training
  • Compliance officer who reports to the governing body
  • Compliance liaisons at each facility

While these requirements could change with the issuance of the Final Rule and surveyor guidance, MPA recommends building your program to meet these guidelines plus OIG guidance – and adjusting your program if and when changes are made.

MPA can help

MPA has SNF compliance programs available for purchase and download on our store. They meet current Phase 3 requirements, and they come with 12 months of updates – if requirements change, MPA updates the program for you at no additional charge. MPA can also conduct your annual review.

Margaret Signature 2020

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Topics: annual review, guidance, compliance, Phase 3, surveys

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