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CMS Resumes Hospital Survey Activities

For licensing and certification staff, legal counsel, directors of nursing

The Centers for Medicare & Medicaid Services (CMS) has announced it will immediately resume hospital survey activities for all complaints. Previously, CMS was operating under guidance — which expired March 22 — limiting surveys to Immediate Jeopardy (IJ) complaints.

Effective March 23, survey activity resumed in accordance with non-long-term care guidance issued on August 17. In the updated guidance, CMS details the following: 

  • Non-IJ hospital complaints received during the survey suspension period beginning Jan. 20, 2021, must be investigated within 45 days of March 23. 
  • During the survey suspension period, hospitals were permitted to delay plan of corrections (POCs) submissions. Providers must submit any delayed POCs within 10 days of March 23, for any surveys that ended on or after Jan. 20, 2021. Hospitals experiencing hardships in developing or implementing a POC due to an ongoing COVID-19 surge should contact their state survey agency or regional CMS office to request an extension.  
  • Desk reviews are permitted of all open surveys cited at any level of noncompliance, except for unremoved IJ findings, which require an onsite revisit. 
  • All onsite revisits are authorized and should resume as appropriate.  
  • Hospitals with open enforcement actions not constituting IJ will have at least 60 days, and up to 90 days, to demonstrate compliance with any outstanding non-IJ deficiencies.