CMS Guidance to State Survey Agencies – Verifying Correction of Deficiencies

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare®

OIG (Office of Inspector General) issued a report last week entitled CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs to be Improved to Help Ensure the Health and Safety of Nursing Home Residents.   OIG looked at a sample of 700 deficiencies.  The Report in Brief provides these highlights:

  • Of the nine selected State agencies in (OIG) previous reviews, seven did not always verify nursing homes’ correction of deficiencies as required.
  • For less serious deficiencies, the practice of six of the seven State agencies was to accept a nursing home’s correction plan as confirmation of substantial compliance with Federal participation requirements without obtaining from the nursing home the evidence of correction of deficiencies.
  • Three of the seven State agencies had technical issues with maintaining supporting documentation in the software-based system used to support the survey and certification process; as a result, they did not have sufficient evidence of correction of deficiencies.
  • If State agencies certify that nursing homes are in substantial compliance without properly verifying the correction of deficiencies and maintaining sufficient documentation to support the verification of deficiency correction, the health and safety of nursing home residents may be placed at risk.

OIG recommends that CMS take specific actions to:

  • reconsider its position on permitting State agencies to certify nursing homes’ substantial compliance on the basis of correction plans without obtaining evidence of correction for less serious deficiencies (deficiencies with ratings D, E, and F without substandard quality of care);
  • revise guidance to State agencies to provide specific information on how State agencies should verify and document their verification of nursing homes’ correction of less serious deficiencies before certifying nursing homes’ substantial compliance with Federal participation requirements;       
  • revise guidance to State agencies to clarify the type of supporting evidence of correction

that should be provided by nursing homes with or in addition to correction plans; 

  • strengthen guidance to State agencies to clarify who must attest that a correction plan

will be implemented by a nursing home;

  • consider improving its forms related to the survey and certification process, such as the

Forms CMS-2567, CMS-2567B, and CMS-1539, so that surveyors can explicitly indicate

how a State agency verified correction of deficiencies and what evidence was reviewed;

  • and work with State agencies to address technical issues with the ASPEN system for

maintaining supporting documentation.

“Under an agreement with the Centers for Medicare & Medicaid Services (CMS), State survey agencies (State agencies) perform surveys to determine whether nursing and skilled nursing facilities (nursing homes) meet specified program requirements, known as Federal participation requirements. During a survey, a State agency identifies certain deficiencies, such as a nursing home’s failure to provide necessary care and services. The State agency must verify that the nursing home corrected identified deficiencies before certifying whether the nursing home is in substantial compliance with Federal participation requirements.” 

Page 17 of the full report shows CMS’ response to each of the 6 OIG recommendations.

This is a very interesting report and I recommend that you share it with your management team.