Survey Revisit Policy Changes

Nursing Homes, August, 2001 by Beth A. Klitch

On May 3, 2001, the Health Care Financing Administration (HCFA), now known as the Centers for Medicare and Medicaid Services (CMS), issued new policies entitled "Verification of Compliance and Setting 3-and 6-Month Remedy Effective Dates." These policies will be used to update Chapter Seven of the State Operations Manual (SOM), and replace the September 22, 2000, memo on this topic. The September policy always required an on-site revisit to certify compliance, but the new policy offers several options for state survey agencies to certify compliance, ranging from accepting a provider's Plan of Correction (PoC) to conducting an on-site revisit.

Let's walk through the detailed provisions of the new policies. First, the new policies take effect with any survey that began a "certification cycle" on or after May 3, 2001 (the date of the memorandum). A certification cycle begins with a recertification (annual) survey or complaint survey and ends when "substantial compliance" is achieved or the facility is terminated from Medicare or Medicaid. In other words, if your facility had an annual survey with deficiencies and it ended on April 30, 2001, and you are still awaiting a revisit to verify compliance, this policy does not apply to you.

Second, "Two revisits are permitted, at the State's discretion, for each certification cycle. A third revisit may be conducted, at the discretion of the (HCFA) Regional Office, and only after it is approved by the Regional Office. Regional Offices are limited to approving only this one additional revisit." HCFA makes it clear that revisits are "not assured," and, depending on the circumstances, "termination can occur anytime for any level of facility noncompliance without regard to revisits." This means that you should request revisits from the state survey agency only when you are certain that your facility has achieved correction of cited deficiencies. If you ask for a revisit and thereafter realize that your facility has not yet achieved correction, you should call the state survey agency and ask that the revisit be delayed. Don't use up a revisit until you are ready for a resurvey!

Third, the methods that state survey agencies use to verify compliance will vary with both the seriousness of your facility's noncompliance and the number of revisits that have already occurred. Let's look at some examples:

* Facility A was surveyed on May 4, 2001, and was found to have three deficiencies. F246 is cited as a "D," F221 is a "B" and F502 is an "E" deficiency. Because none of these deficiencies were cited at an "F" level, constituting Substandard Quality of Care (SQC), the state survey agency will require a PoC but view a revisit as "discretionary"; i.e., they might either accept the latest date on the facility's approved PoC or conduct a revisit.

Facility B is surveyed on May 5, 2001, and is found to have two deficiencies. F314 is cited as an "H" and F272 is cited as an "E" deficiency. Because F314 constitutes SQC, the state survey agency will require a PoC and must perform a revisit to verify compliance. Facility C is surveyed on May 6, 2001, and is found to have one deficiency, F324, cited as an "I" deficiency, constituting SQC. The facility submitted a PoC and alleged that the deficiency would be corrected as of June 6,2001. During the first revisit on June 7, the state survey agency found that F324 remained uncorrected at an "F" level, still SQC. The state survey agency will require a new approved PoC for the uncorrected F324 and must impose an enforcement remedy for this continuing noncompliance. If the facility presents "acceptable evidence" of correction earlier than the date of the second visit, the survey agency might consider this as evidence for establishing an earlier compliance date, but must still perform a second revisit.

Fourth, HCFA has established examples of "acceptable evidence," including, but not limited to:

* An invoice or receipt verifying purchases, repairs, etc.;

* Sign-in sheets verifying attendance of staff at inservice training;

Interviews with more than one training participant about the training received; and

* Contact with the resident council, e.g., when dignity issues are involved.

Fifth, HCFA has set forth some "givens," or principles, for these policies. They include the following statements:

* An approved PoC is required whenever there is noncompliance.

* Remedies can be imposed anytime for any level of compliance.

* Revisits can be conducted anytime for any level of noncompliance.

There are a few more "pearls of wisdom" contained in these new policies, i.e.:

* Revisits are always required to verify the removal of Immediate Jeopardy.

* If noncompliance exists at the time of a revisit, regardless of whether it is new noncompliance or "old" noncompliance, "the fact that noncompliance exists at the time of the revisit constitutes continuing noncompliance.

* When enforcement remedies are imposed against noncompliant facilities, "they cannot be lifted until evidence of facility compliance has been verified."