Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®
Two weeks ago, CMS issued an Administrative Letter – Admin Info: 18-11-NH – reporting Federal oversight activities to “assure the adequacy of the SA’s (State Agency) survey performance following the implementation of the LTCSP.” In short, CMS is auditing how State Agencies are implementing the new survey process. Historically, there has been Federal oversight of state survey agencies so this is not a new process – this is a required function of CMS.
The Letter speaks to the piloting of an interim comparative survey process across several regions and states and acknowledges that software for this pilot has yet to be developed. Regional Office (RO) teams have tried to “manipulate” the existing LTCSP software but that proved to be “too complicated and resource intensive” after three pilot tests. CMS is working to develop and expects to release “comparative-specific software” later this year. Until that software is available, CMS “will not evaluate the results of LTCSP comparative surveys for determination of State Performance Standards. In addition the interim LTCSP comparative survey processes will count toward the CMS comparative survey requirement.”
CMS has issued the following interim policy until a final comparative survey process becomes available:
- Request the SA send their facility matrices (all residents and new admission, if different) and any complaints/FRIs that were investigated with the survey. This information will be reviewed at the end of the survey when citations are compared.
- Conduct the comparative following the LTCSP Procedure Guide.
- Continue to complete the analysis of deficiencies cited and enter the data into the FMS Database.
- For any area cited by the RO and not by the SA, refer to the following items to determine whether the SA should have identified the same noncompliance (e.g., concern was present during SA survey, SA investigated the same resident, or the issue was pervasive across many residents).
- Discuss all findings from the comparative survey with the SA.
There is more specific information beneath the 2nd and 4th bullets above in the letter itself.
Two training sessions were held prior to the posting of this Administrative Letter. The Letter concludes with this statement: “In addition, there have been concerns identified with how the SA’s are implementing the LTCSP. During the training, we will highlight the known SA issues so all ROs are aware of the current struggles for many SA’s. Lastly, during the training, we will discuss RO citations and whether ROs should review emergency preparedness areas if reviewed by the SA.”
This is a good time to remind LTC providers of the Long Term Care Survey Process (LTCSP) Procedure Guide that is available to all parties of the LTC survey process. Make sure you and your staff are familiar with the information in the guide. CMS and State Agencies are using it as their guide as well.