In light of the 2019 novel coronavirus (COVID-19) outbreak, the Centers for Medicare & Medicaid Services (CMS) has suspended survey activity for all nonemergency state survey inspections except for initial certification and recertification surveys. CMS issued a guidance memorandum effective March 4, 2020,¹ which instructs surveyors to prioritize survey and enforcement activity of those categories of surveys that have not been suspended. Although directed toward State Survey Agencies, CMS’s guidance memorandum can also help health care facilities and providers manage expectations and resources with respect to state survey activity.

According to CMS’s guidance memorandum, survey activity will immediately be limited to the following issues, in order of priority:

• all immediate jeopardy complaints and allegations of abuse and neglect

• complaints alleging infection control concerns, including facilities with actual or potential COVID-19 cases

• statutorily required recertification surveys (e.g., nursing home, home health, hospice and ICF/IID)

• revisit surveys necessary to resolve current enforcement actions

• initial certifications

• surveys of facilities with a history of infection control deficiencies at the immediate jeopardy level in the last three years

• surveys of facilities that have a history of infection control deficiencies at lower levels than immediate jeopardy.

Unsurprisingly, infection control issues and deficiencies are at the forefront of CMS’s prioritized survey guidance. As a result of the new priorities, facilities with a recent history of infection control deficiencies can expect increased scrutiny. In addition, facilities with actual or potential COVID-19 patients or residents can expect higher scrutiny, particularly if patients, residents or their caretakers make complaints to regulators.

The presence of actual or potential COVID-19 cases will not, however, necessarily result in on-site surveys. CMS intends to triage reports of adverse conditions at the immediate jeopardy level to determine whether on-site surveys are necessary. Surveyors will have to obtain approval by the applicable CMS Regional Location before conducting on-site surveys. For all issues that do not rise to the immediate jeopardy level, desk audits will be performed and on-site surveys may be authorized once all active or suspected cases of COVID-19 have been cleared from the facility.

Facilities subject to on-site surveys can expect surveyors to focus their scrutiny on concerns with:

• improper transmission precaution procedures

• lack of staff knowledge of transmission precautions

• improper use of personal protective equipment and/or inadequate hand hygiene

• high-risk, significant environmental cleaning issues

• ineffective and/or improper laundering of linens

• possible infection control surveillance program issues.

Undoubtedly, on-site surveys and other surveyor activities can be disruptive to facilities at this critical time. Facilities can, however, potentially mitigate the risk of on-site surveys or other burdensome survey activity by:

• reviewing CMS’s March 4 guidance memorandum, including Attachments A and B, which set forth detailed areas of focus for surveyors²

• ensuring that infection control and related policies and procedures are up to date and in conformance with current laws and regulations

• ensuring that all relevant policies and procedures are properly implemented and communicated to staff

• addressing complaints or issues arising from actual or potential COVID-19 cases in a timely manner.

Since CMS’s top survey priorities are focused on addressing immediate jeopardy complaints, allegations of abuse and neglect and infection control issues, facilities anticipating recertification surveys or seeking initial Medicare certification can expect survey delays. It is important, however, that health care facilities maintain their readiness for recertification surveys, notwithstanding that these surveys are a lower priority for CMS as compared to surveys for more pressing immediate jeopardy and infection control issues.

We will continue to monitor updates from CMS and other government agencies. Nonetheless, health care facilities and providers should proactively monitor any additional guidance, communications and/or directives from CMS and other government agencies.