This past January, and in the middle of a winter surge in COVID-19 hospitalizations, the Centers for Medicare and Medicaid Services (“CMS”) released a Quality, Safety & Oversight Group (“QSOG”) and Survey & Operations Group (“SOG”) memorandum addressed to state survey agency directors that severely limited hospital survey activity for a thirty-day period.  CMS later extended the hospital surveys suspension through March 22, 2021.  As part of the suspension, CMS limited any on-site surveys to complaint surveys involving allegations of immediate jeopardy and noncompliance with Medicare hospital conditions of participation requiring immediate action.  Recertification surveys were also suspended but for a limited number of hospital reaccreditation surveys, and hospital enforcement actions (excluding those that represented immediate jeopardy) were extended for at 30 thirty days.   

On March 26, 2021, CMS released a new QSOG and SOG memorandum, effective immediately upon release, that lifted the surveys suspension and indicated to state survey agencies that on-site activity may resume in accordance with survey guidance that CMS released in August, 2020.  Further, CMS directed that the following actions be taken:

  • Any complaint surveys received during the suspension period that were delayed because of the suspension must be investigated within 45 days.
  • Any hospitals that were permitted to delay submission of a Plan of Correction (“POC”) because of the suspension must submit their POC within 10 calendar days, though any providers experiencing a COVID-19 outbreak in their area and therefore having difficulty implementing a POC may reach out to their state survey agency or CMS and request an extension.
  • State survey agencies may resume offsite “desk reviews” for any open surveys citing any level of noncompliance for the period between January 20, 2021, and March 22, 2021, except for cases involving immediate jeopardy requiring onsite revisits.  
  • For any onsite revisits that are authorized to resume, state survey agencies must ask facilities to submit evidence that supports correction of noncompliance so that a desk review can be performed. State survey agencies may, at their discretion, include the clinical area of concern cleared during a desk review in the next onsite survey.
  • Hospitals with open enforcement actions (excluding those that constitute immediate jeopardy) have at least 60 and up to 90 days to demonstrate compliance. 

Despite the ongoing vaccine distributions, the COVID-19 pandemic continues to be a public health emergency and CMS maintains authority to further modify hospital survey procedures (or even suspend surveys again).  The attorneys at Chilivis Grubman represent clients of all types and sizes in connection with healthcare and facility compliance and will continue to watch for further guidance from CMS on facility survey activities.  If you need assistance with such a matter, please contact us today.