02/03/2022

Survey priorities for FY 2022 released

The Centers for Medicare & Medicaid Services (CMS) released the Fiscal Year (FY) 2022 Mission & Priorities Document (MPD) in the Admin Info 22-03-ALL memo. The MPD is an annual document that directs and outlines the work of Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG), and State Survey Agencies (SAs) based on regulatory changes, adjustments in budget allocations, and new initiatives, as well as new requirements based on statutes.

The FY 2022 MPD includes: 

• Updates to the hospice program based on the Consolidated Appropriations Act (CAA) 2021 
• Several actions for long-term care facilities that were postponed due to the COVID-19 public health emergency (PHE)
• New guidance for the backlog of End-Stage Renal Disease (ESRD) facilities surveys

LeadingAge Ohio will provide additional details on these survey priorities and current survey trends for nursing homes on February 9 during this month’s Survey Tips & Tactics (STAT) call. Hospice regulatory compliance will be covered on March 29 during the Hospice Clinical Bootcamp training.

Hospice Program updates based on the Consolidated Appropriations Act 2021 (CAA 2021) applying to states include:

1. Requirements for standard surveys at least once every 36 months; 
2. Requiring each state to establish a toll-free hospice hotline, to collect and maintain complaint information and questions received concerning hospices in the state. 
3. CMS posting hospice survey reports in a prominent, easily accessible, readily understandable, and searchable manner. 
4. Providing comprehensive training for hospice surveyors; 
5. Prohibiting conflicts of interest for hospice surveyors; 
6. Requiring hospice surveys be conducted by a multidisciplinary team of professionals (including a registered professional nurse); 
7. Conducting a special focus program, which includes conducting more frequent surveys of programs that are found to be noncompliant with applicable standards; and 
8. Applying a range of enforcement remedies to hospice programs that are out of compliance with standards, including civil money penalties (CMPs). CMS plans to release updated guidance on the various requirements and expectations for implementation as guidance is finalized.

CMS plans to implement several actions related to long-term care that were postponed due to the COVID-19 PHE. These actions include: 

1. Revisions to Chapter 5 of the State Operations Manual (SOM) related to the management of facility-reported incidents and complaints, including adherence to federal timeframes for investigation, the collection of mandated elements from the initial and investigation reports, and the collection of data to support the tracking of facility reported incidents. CMS locations will be working with their states to develop a plan for this work. 
2. Guidance for implementing new requirements, or revised guidance for improving the implementation of existing requirements, such as: 

1. Nursing home staff vaccination requirements;
   b. Phase 3 of the Requirements for Participation;
   c. Phase 2 of the Requirements for Participation;
   d. Addressing care for individuals with mental health needs and substance use disorder;
   e. Implementing federal requirements related to the use of binding arbitration agreements; and
   f. Improving the oversight of sufficient staffing.

The MPD discusses survey and certification functions as well as the priority tier structure for survey & certification activities overview. Survey activities must be scheduled and conducted in accordance with the priority tier structure provided in the MPD document. The four priority tiers reflect statutory mandates and program emphases, with tier 1 the highest priority, and tier 4 the lower priority.

Survey priorities for Home Health Agencies (HHAs) include the following:

1. Overview Non-Deemed HHAs: SAs conduct surveys of HHAs to determine whether they are complying with the CoPs. HHAs must be surveyed via a standard survey at least every 36.9 months. This is not an average of 36.9 months; it is a maximum interval between surveys for any one particular HHA. Activation, De-activation, and Change of Ownership (CHOW): since January 1, 2010, a provider or supplier who does not submit any Medicare claims for 12 consecutive calendar months is subject to having its Medicare billing privileges deactivated.
2. Overview of Deemed Home Health Agencies: States will continue to be responsible for conducting two types of validation surveys for deemed HHAs: (1) substantial allegation complaint surveys and (2) representative sample of validation surveys. Each month a sample of scheduled AO surveys is selected for validation. Some states with larger numbers of deemed HHAs have been designated to perform more of these representative sample validation surveys once they have completed the one survey provided for in the standard allocation.

Additionally, QSOG will continue to fund OASIS Education Coordinators (OEC) and OASIS Automation Coordinators (OAC). The OECs will provide technical assistance to the HHA providers in the administration of the OASIS data set. The Division of Chronic and Post-Acute Care (DCPAC) has assumed responsibility for the technical support to OECs. The OACs will provide technical assistance to the HHA providers on the transmission of OASIS data. The Division of Quality Systems for Assessments and Surveys (DQSAS) continues to provide technical support to the OACs. Contact information for OECs and OACs in each state is located on the following CMS website: OASIS Education Automation Coordinators.

Survey priorities for Hospice Agencies include the following:

1. The requirement to survey hospice programs every 36 months was initially established in the IMPACT ACT 2014 and has been extended recently under the CAA 2021. When there are nursing home residents that have elected Medicare hospice services, the SA is expected to have a system in place for nursing home surveyors to report to the SA of those nursing facilities which are providing hospice services to residents and any concerns they have about the provision of hospice services in a specific facility. The SAs are expected to follow up and initiate enforcement action against a hospice when they identify hospice non-compliance issues associated with care to nursing home residents who have elected the hospice benefit.
2. Deemed Hospice Agencies: States will continue to be responsible for conducting two types of validation surveys for deemed hospices: (1) substantial allegation complaint surveys and (2) representative sample validation surveys. Each month a sample of scheduled Accrediting Organization (AO) surveys is selected for validation. Some states with larger numbers of deemed hospices have been designated to perform more of these representative sample validation surveys once they have completed the one survey provided for in the standard allocation. Hospice surveys should include a sample of multiple locations in the survey process.

Survey priorities for Long-term Care include the following:

Skilled nursing facilities (SNFs) and nursing facilities (NFs) are subject to a standard survey that is completed no later than 15.9 months after the previous standard survey, with a statewide average between standard surveys of 12.9 months. 

• Off-hours Surveys: States must continue to conduct 10% of nursing home inspections off-hours (to be started mornings, evenings, and/or weekends). 
• Resident Assessment Instrument/Minimum Data Set (RAI/MDS): All certified nursing homes and swing bed hospitals are required to encode and transmit MDS records to CMS in accordance with CMS established specifications and time frames. CMS expects the states to continue to provide staff to serve as RAI/MDS educational and technical resources to nursing homes and SA staff including educating providers and SA staff on reports from the data system, MDS outcome, or other reports. 
• Focused Infection Control Surveys: States must perform annual Focused Infection Control surveys of 20% of nursing homes based on state discretion or additional data that identifies facility and community risk, such as facilities in counties with high rates of COVID-19 community transmission, facilities with multiple weeks of reporting COVID19 cases, Special Focus Facilities (SFFs), facilities identified as candidates for the SFF program, or facilities with allegations or complaints which pose a risk for harm or Immediate Jeopardy to the health or safety of residents. 
• Maintenance of Nurse Aide Training Registry: States are required to maintain a registry of all individuals who have completed a nurse aide training course and have passed a competency evaluation test. States must also investigate allegations of resident neglect and abuse (including misappropriation of personal funds) by a nurse aide or other individuals. 
• Review of Requests for Waiver of Nurse Aide Training Program two-year Prohibition: States are required to maintain a list of approved nurse aide training programs. If a program is disapproved due to survey findings, the state has specific authority under the statute to review requests for waiving the disapproval particularly for those facilities where access to other approved programs is an issue. Please see S&C-18-02-NH memo for additional clarification. 
• Enforcement and Civil Money Penalty (CMP) tool: CMS will continue to work on enforcement policies to support compliance. States are required to transfer all cases that warrant enforcement to the CMS location. 
• State reinvestment of CMP funds: States are required to reinvest CMP funds to improve and protect the health and safety of nursing home residents. CMS has provided additional guidance via Admin Info memo (Admin-18-16-NH). 
• Emergency preparedness surveys: Please refer to the Emergency Preparedness website for additional information for these requirements and surveys. 

Updates to the Standard Health Survey Process include:

• All states must use the long-term care survey process (LTCSP) to assess compliance with the Requirements for Participation (RoP). CMS will continue to make software and guidance updates to existing and new regulations and will update the LTCSP Procedures Guide and Training documents accordingly. 
• Resources for all of these changes can be found on QSEP and at Guidance to Laws & Regulations: Nursing Homes

Other areas of importance include:

National Partnership to Improve Dementia Care: CMS has partnered with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve comprehensive dementia care. CMS and its partners are committed to finding new ways to implement practices that enhance the quality of life for nursing home residents with dementia through promoting goal-directed, person-centered care for every nursing home resident. CMS continues to focus on reducing the use of antipsychotics and enhancing the use of non-pharmacologic approaches and person-centered dementia care practices in all nursing homes when their use is not clinically indicated. Also, CMS plans to evaluate actions to address concerns about facilities using an inappropriate process to diagnose residents with schizophrenia to improve their quality measures artificially. CMS will communicate any new updates or initiatives as this review progresses.

Preventing discharges that violate federal requirements (also known as "involuntary discharges"): CMS remains concerned when residents are discharged in a manner that violates federal requirements and places resident's health and safety at risk. CMS requires states to transfer any case that involves noncompliance related to involuntary discharge to their CMS Location.