The words a provider never wants to hear from a surveyor… there may be jeopardy. Skilled nursing centers must be in substantial compliance with Medicare and Medicaid requirements at all times and are always responsible for the health and safety of their residents. The provider should be surveyor- ready everyday, and that means when something goes wrong, the facility should be proactive and begin the correction process immediately. When the surveyor comes in to investigate a self-report or discovers something the facility has already self-identified, there should be a clear path to QAPI that the issue has been corrected.
The first thing a provider must do when they have discovered a weakness or an opportunity for improvement is an investigative process. The investigative process must be thorough with statements from everyone involved so the QAPI team can see the entire picture. The QAPI team must determine if this is a human error or a system failure. Once the weakness is identified, the Performance Improvement Plan must be created and implemented. All this documentation will assist surveyors and the CMS Regional Office to determine remedies to be imposed. QSO 18-18-NH gives guidance on how the CMS Regional Offices will consider the extent to which the cited noncompliance is a one-time mistake or accident, the result of larger systemic concerns, or a more intentional action or disregard for resident health and safety in order to select a remedy that protects the health, safety and well-being of patients by encouraging the facility to quickly achieve compliance with Medicare and Medicaid requirements.
If the event is a reportable event, most likely a survey will follow after notification. The surveyor will investigate the event along with the corrections implemented. A good practice is to create an Acceptable Plan of Correction or APOC. An acceptable plan of correction must address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; address how the facility will identify other residents having the potential to be affected by the same deficient practice; address what measures will be put into place or systemic changes made to ensure the deficient practice will not recur; indicate how the facility plans to monitor its performance to make sure solutions are sustained; and include dates when corrective action will be completed. The plan of correction serves as the facility’s allegation of compliance and without it, CMS and the Agency for Health Care Administration have no basis on which to verify compliance.
Past noncompliance may be identified during any survey. To cite past noncompliance with a specific survey data tag, all of the following three criteria must be met:
- The facility was not in compliance with the specific regulatory requirement(s) at the time the situation occurred;
- The noncompliance occurred after the exit date of the last standard survey and before the survey currently being conducted; and
- There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement.
The skilled nursing center does not need to provide a plan of correction for a deficiency cited as past noncompliance because the deficiency is already corrected; however, the survey team documents the facility’s corrective actions on the CMS-2567. Further reference on Immediate Jeopardies (IJs) and enforcement can be found in State Operations Manual.