March 31, 2016

Ready to Exit? CMS Issues Survey & Certification Memo

Kris B. Harmony, OTR/L, LNHA, MBA

Kris B. Harmony, OTR/L, LNHA, MBA

On March 11, 2016 the Centers for Medicare and Medicaid Services (CMS) issued Survey and Certification Memo 16-11-ALL to the State Survey Agency Directors.  This memo was made public to providers, and it clarifies guidance to surveyors regarding the procedure for conducting the Exit Conference of a survey.  The memo was issued due to many questions to the CMS regarding the level of specificity that surveyors should give during the Exit Conference regarding the deficiencies found during the conduct of federal surveys.  The policy will affect all Surveyors conducting Federal surveys and for all types of Federal Surveyors.  The CMS has revised the State Operations Manual (SOM), Chapters 2 and 5, and Appendix P to reflect these changes.

The Exit Conference is conducted at the conclusion of the survey, and is intended to be a courtesy to the facility.  An Exit Conference is not a requirement, as is noted in Section 2724 of the SOM.  The purpose of the Exit Conference is to informally communicate preliminary survey team findings and provide the opportunity for the exchange of information with the Provider's or Supplier's Administrator, Designee, or other invited staff.  The memo stresses that the information that is provided during the Exit Conference is preliminary, and is subject to change based on review by the State and CMS supervisory review process. 


Long Term Care Facilities are instructed to look to the SOM Appendix PP for the interpretive guidelines, explanations, and resource materials that can be found under many deficiency codes.  This information is intended to guide the Long Term Care Facility in understanding relevant deficiencies as well as in planning remedial actions.  If during the course of the Exit Conference, the Long Term Care Provider asks for the specific regulatory basis or the specific tag code, the Surveyor should generally provide this information.  However, Surveyors are instructed that under no circumstances should information about Scope and Severity be given, unless the deficiency is an immediate jeopardy.  The finer level of detail that is necessary to provide Scope and Severity will be conducted during the supervisory review.  The information that is provided regarding the deficiencies found during the survey should always be viewed as preliminary, and potentially subject to change upon supervisory review.  The final deficiency codes, as well as Scope and Severity, are addressed in Form CMS-2567, Statement of Deficiencies. 


If during the Exit Conference, the survey team is still deliberating what the Scope and Severity a deficiency will be, the team is instructed not to speculate the Scope and Severity during the Exit Conference.  Similarly, if the survey team feels they need to consult with other State personnel prior to determining the appropriate Scope and Severity they should not provide a speculation as to the Scope and Severity of the tag.  The decision about how much detail to provide during the Exit Conference is a survey-specific decision based on the evidence gathered during the survey.  If a Provider inquires as to the Scope and Severity of a deficiency, the Surveyor should respond with the facts, for example, the deficiency affected X number of residents. 


Because all states are subject to the federal process, state laws do not override procedures outlined in the federal survey process.  Therefore, States are not permitted to require surveyors to always provide certain information during the Exit Conference.


Kris B Harmony recommends that Long Term Care facilities review this important S&C Memo and become informed about the level of detail that Surveyors can share at the Exit Conference.  Long Term Care facilities are encouraged to use the Exit Conference as a forum to obtain information about deficiencies found during the survey and begin to plan corrective action.  When the facility receives the Form CMS-2567, Statement of Deficiencies they will have the final determination of the specific survey deficiency tag, Scope, and Severity. 

If you have questions about the Survey and Certification Memo, please contact Kris B Harmony by clicking here or calling our office at (617) 595-6032.

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