The memo (QSO-21-16-Hospitals) directed state survey agencies to follow CMS’s prior guidance regarding survey activities, which CMS circulated in August 2020 and which we previously summarized.

The memo emphasizes specific guidance that hospitals should keep in mind:

• Surveyors must investigate non-immediate jeopardy complaints within 45 days of the memo (by May 10, 2021).
• Providers with open surveys with cited deficiency tags whose requirement to submit a plan of correction was delayed by the prior suspension of surveys must now submit those plans within 10 calendar days of the memo (by April 5, 2021).
• If providers are unable to complete and implement a plan of correction because of COVID-19 outbreaks in their area, they should contact their state survey agency to request an extension.
• State surveyors are not obligated to conduct onsite visits or revisits for any level of noncompliance that has been suspended from January 20, 2021, through March 22, 2021, except for unremoved immediate jeopardy situations. This means that remote desk reviews may be conducted on immediate jeopardy citations that have been verified as removed or downgraded to a lower level of noncompliance.
• As of March 23, 2021, state surveyors are authorized and directed to resume onsite revisits of hospitals demonstrating deficiencies cited in plans of correction when applicable pursuant to State Operations Manual Chapter 2, Section 2732. Generally, onsite visits are required for deficiencies related to quality of care. Remote desk reviews can process many other deficiency citations where evidence of remediation does not require personal observation. Acceptable evidence may include dates of training, attendance rosters, evidence of competency, monitoring for policy implementation and staff adherence to the policy.
• If state surveyors are concerned about any immediate jeopardy citations cleared with a remote desk review, the clinical area of concern may be included as part of the next onsite survey.
• Providers with non-immediate jeopardy enforcement actions will have 60-90 days from the memo to demonstrate compliance with any outstanding deficiencies.

Because COVID-19 remains a public health emergency, CMS has discretion to re-suspend hospital surveys if circumstances require. However, this action forecasts that CMS expects hospitals to continue providing high-quality services to patients, and any continued relaxation of enforcement efforts is likely to be short-lived.

Key Takeaways

Hospitals with outstanding survey activities or plans of correction should review the new CMS timelines for review and take immediate action to address outstanding obligations. Hospitals that anticipate ordinary course survey activities (e.g., related to new complaints, or pending survey cycles) should expect those to proceed with onsite survey activity. Major accrediting organizations, including The Joint Commission and DNV, have also announced plans to increase onsite, unannounced survey activity in line with CMS guidance, signaling a return to a robust hospital accreditation and survey environment.