CMS issued a memorandum on April 19, 2013, “Update of State Operations Manual (SOM) Chapter 5, Complaint Investigation.” One of the key changes listed is that the requirement for conducting a full survey after a complaint survey that results in condition-level findings will be decided by the Regional Office (RO) on a case-by-case basis. This move is meant to help CMS utilize its resources more efficiently.
The letter provides several factors that the RO can use to decide whether a full survey is warranted or not, including:
- The degree of non-compliance identified from the complaint survey
- The facility’s prior survey history
- Changes to the facility’s ownership/management
- If CMS has the resources available to conduct the survey within the required timeframe
- How long it has been since the facility’s last certification survey
Draft revisions to Chapter 5 of the SOM are included in these areas:
- 5110.1 – Substantial Compliance
- 5110.2 – Condition-Level, IJ
- 5110.3 – Condition-Level, Non-IJ
- 5110.4 – Full Survey after Complaint Survey with Condition-level Deficiencies, When authorized by RO
In addition to making the changes to the full survey requirement after a complaint survey, CMS has reminded all ROs that a copy of all survey findings and any relevant additional materials must be sent to CMS at the same time they are sent to the facility. Additionally, the 2567 Statement of Deficiencies and Plan of Correction must be completed in ASPEN for every on-site survey that takes place.
Want to know more about IJ situations? Check out CMS Compliance Group’s 4-part blog feature on nursing home immediate jeopardy citations.