February 3, 2021

Do you remember when rules were set in stone? No matter what the extenuating circumstances or the reasonable excuses, the rules were the rules and they were to be followed without exception. Well, that hardnosed notion has become a bit mushy as of late, what with all the government waivers and temporary measures and turning a blind eye during the current public health emergency (PHE). It seems as if the tight-run ship approach has become more akin to a party barge where anything goes.

Of course, a relaxation of the rules in times of crisis is not necessarily a bad thing. In fact, in the minds of many, it has become downright essential—especially for those in the healthcare industry who are trying to save lives while simultaneously struggling to stay afloat. Many are thankful to a responsive government that knows when to ease up on the enforcement and let certain things slide. Such is the case for a temporary ruling issued by the Centers for Medicare and Medicaid Services (CMS) late last month.

Relaxing the Rigor

On January 20, CMS directed its surveyor agents to significantly relax their scope of operations within the hospital setting for 30 days from the issuance of the directive. Moreover, this temporary guidance is subject to possible renewal involving additional 30-day periods. The move was sparked, in part, by a request from the American Hospital Association (AHA) to eliminate or severely restrict surveying activities during the pandemic. In response, CMS has announced that, during this initial 30-day period, it will be suspending certain hospital surveying activities as reflected below:

Hospital Complaint Surveys

These will be restricted to “Immediate Jeopardy” complaint allegations. According to a CMS memorandum on the temporary survey restriction, the agency will place a priority on onsite complaint investigations pursuant to the following circumstances:

Imminent danger to patients at the hospital;
Noncompliance with Medicare Hospital Conditions of Participation (COPs) likely exists; and
Immediate action must be taken to protect the health and safety of patients.
The agency made clear that such investigations will be limited to those COPs that are needed to ensure the health and safety of patients who are in imminent danger. An investigation of the Infection Control COP will only be authorized by CMS if the allegations support findings in this area. Focused Infection Control surveys will be required by CMS only for those complaints with allegations that support their inclusion.

The CMS memorandum went on to state: “While the circumstances above outline the priority expectations, CMS may authorize onsite investigations anytime, as determined appropriate by the CMS Survey Operations Group Location.”

Hospital Recertification Surveys

These surveys will be suspended, “except for a subset of hospital reaccreditation surveys, per additional guidance that will be forthcoming,” according to CMS. Notably, those hospitals that are scheduled to soon receive a recertification or reaccreditation survey will have their certification automatically extended for at least 30 days, due to this directive.

The CMS memorandum of January 20 asserted that additional guidance on “Accrediting Organization” reaccreditation surveys will be forthcoming. In addition, such organizations will be directed to halt their reaccreditation surveys for 30 days “and instead perform a targeted sample of reaccreditation surveys using a modified survey process in hospitals that meet defined parameters.”

Hospital Enforcement Actions

Lastly, the CMS directive of January 20 on this topic noted that “actions for deficiencies that do not represent Immediate Jeopardy will have their termination date extended for at least 30 days.” In other words, hospitals will not need to submit a plan of correction nor will a revisit survey by the State Survey Agency be required. This is to include “desk reviews.” According to CMS:

Hospitals that have an uncorrected Immediate Jeopardy must demonstrate removal of the Immediate Jeopardy findings through an onsite survey. Once the Immediate Jeopardy has been removed, the above protocol will apply.
Returning to Reality

All of this allowance and abeyance will not run on in perpetuity. Following this 30-day period (or any announced subsequent 30-day periods), “hospitals will have up to 60 days to demonstrate compliance with any outstanding deficiencies,” per the CMS memorandum. The agency will be issuing further guidance pertaining to these temporary survey provisions prior to their termination.

For more information on, and to keep track of, the survey suspension directives, please go to the following CMS link: Hospital Survey Priorities | CMS. As always, if we can help you in any way or if you have questions about our services, you can contact us at info@miramedgs.com.