CHA News

CMS Directs CDPH to Resume Specified Enforcement Activities

For licensing and certification staff, patient safety and quality staff

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On Aug. 17, the Centers for Medicare & Medicaid Services (CMS) released guidance QSO-20-35-ALL, which directs State Survey Agencies, including the California Department of Public Health (CDPH), to resume specified enforcement activities that had previously been suspended.  

Hospitals have until Aug. 27 to submit their Plans of Corrections for surveys that ended prior to June 1. However, hospitals that may have difficulty allocating resources to develop and implement a Plan of Correction because they are currently experiencing an outbreak of COVID-19 in their area should contact their CDPH District Office to request an extension.  

CMS has expanded desk review for these outstanding enforcement actions held from prior to June 1. As a result, CDPH can perform desk reviews for all open surveys that cited any level of noncompliance, including noncompliance that was cited at the Immediate Jeopardy (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. CDPH must request and receive evidence from a hospital that supports correction of noncompliance for a desk review to be performed.   

As of June 1, all onsite revisits are authorized and should resume, as appropriate. CDPH has informed CHA that it is assessing whether to resume these onsite visits. CMS also directs states to resume normal survey activities when the state has entered Phase 3 of reopening (based on White House Guidance for State/Regional reopening) or earlier at the state’s discretion. CDPH has confirmed that it does not plan to resume normal survey activities, on behalf of CMS, given the impact of COVID-19 in California. 

This guidance also directs CDPH to resume specified enforcement activities for skilled-nursing facilities (SNFs). Generally, CDPH does not plan to resume normal survey activities, on behalf of CMS, for SNFs. 

CDPH is expected to release an All Facilities Letter that describes its federal certification and state licensing work that might result in its contacting or visiting a hospital in the next few weeks.