The Centers for Medicare & Medicaid Services (CMS) issued Advance Guidance to surveyors on the procedures for conducting Exit Conferences at long term care facilities as well as for non-LTC providers/suppliers. The Agency issued this letter to “ensure uniformity in the survey procedures” – mainly to ensure that States know they must follow the federal process, including that States are not allowed to require surveyors to provide a specific set of information during Exit Conferences.
CMS reiterates the word “informal” throughout the letter in regards to the Exit Conference, noting that the purpose of the Exit is to informally communicate preliminary survey team findings and to provide an opportunity for the exchange of information. Specific details about what surveyors can and cannot do under the federal process were reviewed. For instance:
- Surveyors should generally provide information related to specific tag codes, but must caution the facility that these classifications are preliminary and that they are only provided to help the facility gain additional insight into the issues found by using the interpretive guidance.
- If the team is still deciding what tags will be cited, the surveyors may not speculate at the Exit as to which tags will be cited.
- If the surveyors require consultation with additional State personnel, they can generally describe the area of non-compliance without stating specific tags.
There is the reminder that State surveyors should “under no circumstances” provide the Scope and Severity of a given deficiency finding unless it is Immediate Jeopardy because a supervisory review must be conducted first. The revised Guidance updates the language of SOM Chapter 5 5340 Post-Survey Certification Actions for Nursing Homes to tweak the responsibilities of the SA for conducting a supervisory review of the 2567: “Following the investigation, the survey team records any findings on Form CMS-2567, the SA conducts a supervisory review of the CMS-2567 form and sends the provider a copy. The SA requests a POC for any uncorrected deficiencies.”
CMS reminds SAs that the “integrity of the State and CMS post-survey quality review process is central to having well-supported, evidenced-based deficiency findings that appropriately establish the level of harm or potential for harm to the patient/resident.” It also clarifies that States are not allowed to leave draft CMS-2567 forms onsite at the provider before they are finalized. It looks like survey deficiencies will be getting a harder look in coming days by SAs with the tweaks to the Guidance to Surveyors. Whether this will result in more or less deficiencies or higher scope and severity level deficiencies is left to be seen.
Read CMS S&C Letter: “Exit Conferences – Sharing Specific Regulatory References or Tags” (Ref: S&C 16-11-ALL) on the CMS website.
If you are preparing for an upcoming survey or need assistance with a Plan of Correction, Directed Plan, or Directed InService, CMS Compliance Group’s consultants can assist you. Contact us today to learn more.