CMS Guidance for Life Safety & Emergency Preparedness Federal Monitoring Surveys

On November 20, 2023, the Centers for Medicare & Medicaid Services (CMS) issued guidance for Federal Monitoring Surveys. Long Term Care Federal Monitoring Surveys (aka validation surveys) are conducted by Federal CMS locations during each Fiscal Year (FY). In a prior post on the CMSCG Blog, we reviewed everything you need to know for the LTC Health FMS. However, it’s not just Health surveys that get an extra look from the Feds. It’s also Life Safety Surveys and Emergency Preparedness. Let’s look at what’s underway this FY.

LSC and Emergency Preparedness FMS

Much like the Health FMS, there are different survey processes for Life Safety and Emergency Preparedness – LSC Resource and Support Surveys (LSC RSS), LSC Comparative Surveys, and two types of revisit surveys, LSC Revisit Resource and Support Survey (LSC RSS) and LSC Revisit Comparative. Here’s an overview of each FMS.

  • LSC RSS – An LSC RSS occurs at the same time as a facility’s Life Safety survey. A Federal surveyor is expected to provide training and/or technical assistance as he/she observes and assesses the State survey team’s performance. The Federal surveyor will complete a FMS LSC RSS State Report to document the survey’s findings and highlight guidance that was provided during the survey so it can be used as a learning tool for all surveyors.
  • LSC Revisit RSS – During this type of FMS, a Federal surveyor observes and assesses the State Agency’s survey team performance during an on-site revisit. If training or assistance is needed, the Federal surveyor will do this while onsite.
  • LSC Comparative – A Comparative survey occurs after a standard survey is conducted by the State Agency (SA), within 60 calendar days of the standard survey. This is a full survey conducted by a Federal surveyor to monitor the State survey team’s performance where all investigative protocols will be used. That’s not all – an Emergency Preparedness survey will be conducted with every Comparative survey.
  • LSC Revisit Comparative – The purpose of this Federal Monitoring Survey is to evaluate the performance of the State surveyors. A Federal Revisit Comparative survey will occur within 60 calendar days of a State revisit survey. The Federal surveyor is primarily responsible for evaluating compliance with the issues cited during the standard survey but will also include an EP survey.

How Emergency Preparedness is Evaluated

Since the Emergency Preparedness regulations went into effect, review of compliance with E-tags has been spotty and minimal in some cases, and extremely thorough in others. This has left CMS and even the Office of the Inspector General (OIG) very concerned about what would happen in an actual emergency. So, as we know, once something gets a lot of OIG attention, it often results in a lot of CMS attention as to what the survey teams are doing during their reviews and can result in survey findings/deficiencies. That said, it may be wise to take that Emergency Plan that’s likely collecting dust in the corner and see if it needs a review to ensure its current and compliant with regulatory expectations.

As far as Federal Monitoring Surveys, let’s look at what’s required. As mentioned above, an EP survey will occur after there is a LSC Comparative or LSC Revisit Comparative survey.  Since State Agency survey assignments can be different regarding who reviews compliance with Emergency Preparedness (EP) regulations, the Federal LSC Surveyor will be assigned differently depending on the circumstances. This creates several scenarios to be aware of related to LSC RSS and LSC Revisit RSS:

  • Emergency Preparedness review assigned to SA Health surveyor – If the Federal LSC surveyor is onsite when the SA Health surveyor will complete the EP portion of the survey, the Federal surveyor will accompany the Health surveyor examining the E-tags for only that portion of the survey. If the Federal surveyor is not onsite at the time the Health surveyor completes the EP survey, the Federal LSC surveyor will evaluate the EP regulations.
  • Emergency Preparedness review assigned to a SA LSC surveyor who reviews both LSC and EP – The Federal surveyor will conduct both LSC and EP survey with the SA surveyor.
  • When a LSC Revisit RSS is taking place, the Federal surveyor will evaluate all EP regulations, regardless of how EP citations are evaluated by the State Agency’s surveyors.
  • If multiple State surveyors are conducting the LSC and EP portions of the survey, the Federal surveyor will accompany different surveyors during these evaluations.

Ultimately, the support that Federal surveyors are providing to survey teams to ensure they understand the regulations, apply the survey process correctly and apply the principles of documentation as expected will likely lead to tougher, harder-to-dispute citations.

View the full Memo here for more details.

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