Updated August 19, 2020

WASHINGTON, D.C. (August 18, 2020)—The Centers for Medicare & Medicaid Services (CMS) announced it will resume routine inspections of all Medicare and Medicaid certified providers and suppliers to improve the safety and quality of life of patients and residents. CMS had previously suspended certain routine inspections as part of its response to the coronavirus disease 2019 (COVID-19) pandemic to prioritize infection control and immediate jeopardy situations and to give health care providers and suppliers time needed to respond to the spread of COVID-19.

“At President Trump’s direction, CMS has worked closely with states to complete focused infection control surveys of virtually all nursing homes in the country in just a few months,” said CMS Administrator Seema Verma. “These surveys fortified health care facilities around the country to prepare for and implement actions to prevent transmission of the virus and provided indispensable insight into the situation on the ground. As CMS resumes some survey and enforcement activities that were previously put on hold, the health and safety of America’s patients will always be our top priority.”

In the guidance released today, CMS directed the resumption of onsite revisit surveys, non-immediate jeopardy complaint surveys and annual recertification surveys as soon as resources are available. In addition, CMS is providing guidance on resolving enforcement cases that were previously on hold because of survey prioritization changes. The agency will also temporarily expand the desk review policy, when state surveyors ensure that facilities return back into compliance with federal requirements without an onsite survey, to include all noncompliance reviews except for immediate jeopardy citations that have not been removed.

On July 31, CMS posted the latest results from the targeted nursing home infection-control inspections. Since March 4, CMS and its network of state-based inspectors have conducted more than 15,158 surveys, reflecting a 98.5% completion rate, with a total of 16,987 survey reports publicly available on Nursing Home Compare. CMS has imposed more than $15 million in civil money penalties (CMPs) to more than 3,400 nursing homes during the public health emergency for noncompliance with infection control requirements and the failure to report COVID-19 data.

CMS is also issuing updated guidance for the re-prioritization of routine state survey agency activities on Clinical Laboratory Improvement Amendments. This updated guidance will provide flexibility and discretion to state survey agencies so that they can resume their survey activities based on the status of COVID-19 infections in their states.

CMS is also posting updates to the “Toolkit on State Actions to Mitigate COVID-19 Prevalence in Nursing Homes.” The toolkit details actions and best practices by organizations, state governments nationwide, and U.S. territories to assist nursing homes in meeting the needs of nursing home residents since the onset of the pandemic. The toolkit is updated on an ongoing basis to ensure it contains the most recent information available for providers and administrators of nursing homes to learn from an array of creative plans that state governments and other public health entities have put in place in a short period of time to contain the spread of the virus in nursing homes and meet the needs of America’s most vulnerable.

CMS is committed to protecting the beneficiaries it serves. The agency develops and enforces federal safety standards across the healthcare system. CMS’s network of federal and state inspectors, as well as private accrediting organizations for some types of providers with programs approved by CMS, physically visit Medicare and Medicaid-participating health care providers to ensure compliance with these standards—including over 15,000 Medicare and Medicaid certified nursing homes.

Non-Long-Term Care Guidance

In addition to guidance for nursing homes, CMS issued the below guidance for providers in non-long-term care situations.

Expanded Survey Activities: In addition to ongoing focused infection control surveys, CMS is encouraging states to resume normal survey activities, while also addressing the backlog of surveys that were postponed as directed in QSO 20-20-All. Once a state has entered Phase 3 of reopening (based on White House Guidance for State/Regional reopening) or earlier at the state’s discretion, states should resume normal survey activities according to guidance in the FY 2020 Mission & Priority Document, while prioritizing their survey backlog as follows (in descending priority):

  • Revisit surveys for past non-compliance that do not otherwise qualify for a desk review;
  • Complaint surveys triaged as non-IJ level or higher that have not been completed;
  • Special Purpose Renal Dialysis Facilities (SPRDFs);
  • Initial surveys of new providers;
  • Past-due recertification surveys with a statutorily required survey interval; and
  • Past-due recertification surveys without a statutorily required survey interval.
  • During the period of the COVID-19 PHE, surveyors should continue to utilize the COVID-19 Focused Infection Control Survey: Acute and Continuing Care specified in QSO-20-20-All as part of any survey that is conducted. CMS will provide additional guidance on the timeframe for resumption of validation surveys at a future date.

While CMS recognizes that resumption of surveys will depend on state reopening plans, staffing, and resources, CMS is requesting that states work with their respective CMS locations to discuss plans and proposed timeframes for completion of required surveys postponed due to the COVID-19 PHE.

Accrediting organizations with Medicare-approved programs may resume normal activity based on state reopening criteria. Any variations from the approved reaccreditation survey process must receive CMS approval prior to implementation.

Addressing Prior Enforcement Cases:  When the QSO 20-20-All memorandum went into effect, CMS locations were directed to suspend enforcement cycles with the exception of unremoved IJs, to target focused infection control and IJ surveys.

CMS intends to resolve those enforcement cases which were suspended. For non-long-term care providers and ICFs/IID, CMS is expanding the desk review policy for Plans of Corrections.

Expanded Desk Review Policy:  Under the QSO 20-20-All memorandum, enforcement cases were held, and providers were permitted to delay the submission of a plan of correction until the prioritization period ended. All open surveys with cited deficiency tags must have an acceptable plan of correction and supporting evidence in order for the tags to be corrected.

Providers have 10 calendar days from the effective date of this guidance to submit their plan of correction for surveys that ended prior to June 1, 2020. Plans of correction for surveys that will end on or after June 1, 2020, will follow the normal plan of correction submission process.

NOTE: Providers who may have difficulty allocating resources to develop and implement a plan for correction because they are currently experiencing an outbreak of COVID-19 in their area should contact their SA and/or CMS location to request an extension on submitting a plan for correction.

State surveyors can perform desk reviews for all open surveys that cited any level of noncompliance, including noncompliance that was cited at the IJ level when the IJ finding has been verified as removed or moved to a lower level of noncompliance. The only exception to the expanded offsite review policy is unremoved IJs, which require an onsite revisit. This expanded desk review policy applies only to outstanding enforcement actions which were held per QSO 20-20-All memorandum, from March 23, 2020, through May 31, 2020.
Beginning June 1, 2020, all onsite revisits are authorized and should resume, as appropriate, per SOM, Chapter 2, Section 2732.

State agencies must request facilities to submit evidence that supports correction of noncompliance so that a desk review can be performed based on the latest compliance date on the plan of correction. NOTE: A desk review cannot be completed without supporting evidence from the facility. This evidence may include dates of training, staff in attendance, and evidence that staff were evaluated for skill(s) competency when applicable. It may also include monitoring for policy implementation and successful performance by staff.

To alleviate any concerns related to correcting noncompliance cited at IJ, or remaining noncompliance following removal of IJ without an onsite revisit, SAs have discretion to include the clinical area of concern cleared using the desk review on the next onsite survey conducted. For complaints, surveyors should add the area of concern following normal procedures for complaint investigations in SOM Chapter 5.

To view memo to state agencies, please go here.

To view toolkit to nursing homes, please go here.