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CMS resuming routine hospital surveys after delays

Any complaints received during the suspension period will be investigated within 45 days; correction plans are required.

Jeff Lagasse, Associate Editor

(Photo by Morsa Images/Getty Images)(Photo by Morsa Images/Getty Images)

Late last week, the Centers for Medicare and Medicaid Services lifted a suspension on hospital surveys and said most on-site survey activity will now resume as normal.

CMS put a freeze on most hospital surveys on Jan. 20, in the midst of a mid-winter surge in COVID-19 cases and hospitalizations. Originally slated for 30 days, the suspension period was extended through March 22, with only immediate jeopardy complaints investigated.

Now, with normal activity resuming, any complaints received during the suspension period will be investigated within 45 days. Correction plans will be required for deficiencies found during surveys performed on or after Jan. 20.

Desk Reviews are permitted of all open surveys cited at any level of noncompliance, except for unremoved non-immediate jeopardy (IJ) findings, which require an onsite revisit. Onsite Revisits are authorized and will resume, and open enforcement cases that are not IJ will have at least 60 days, and up to 90 days, to demonstrate compliance with any outstanding deficiencies.


On Jan. 20, CMS issued QSO-21-13-Hospitals, which limited hospital surveys for 30 days to include only immediate jeopardy complaint allegations suggesting imminent danger to patients at the hospital, or noncompliance with Medicare hospital conditions of participation. It required immediate action to protect patient safety. 

Hospital recertification surveys were suspended except for a subset of hospital re-accreditation surveys. Hospital enforcement actions for deficiencies that did not represent immediate jeopardy had their termination date extended for at least 30 days. On Feb. 18, CMS extended these hospital survey limitations for an additional 30 days until March 22.

The survey limitations were lifted as of March 23. 

Providers were allowed to delay the submission of a plan of correction (POC) until the survey suspension period ended. All open surveys with cited deficiency tags must have an acceptable POC and supporting evidence in order for the tags to be corrected. Providers have 10 calendar days from the effective date of the guidance to submit their POC for surveys that ended on or after Jan. 20.

Those who may have difficulty allocating resources to develop and implement a POC because they're currently experiencing an outbreak of COVID-19 in their area should contact their state survey agency or CMS location to request an extension on submitting a POC.


As of March 29, the Johns Hopkins University coronavirus tracker showed more than 30.2 million confirmed cases of COVID-19 in the U.S., with the death toll climbing to over 549,000. Both figures lead the world. Brazil comes in a distant second with about 12.5 million confirmed cases and more than 12,000 deaths recorded to date.

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