Please contact Jerri Lynn Ward for more information.
Posted November 12, 2001
On May 3, 2001, the Department of Health & Human Services (DHHS) officially amended their Verification of Compliance policy.
What are the amendments?
Before May 3, 2001, DHHS required an onsite visit to a facility to confirm compliance and stop remedies. DHHS introduced a new mechanism through which a facility may accomplish these goals. Now, a facility may, after May 3, 2001, provide evidence of compliance rather than submit to a visit if needed corrections do not necessitate an onsite visit. Examples of evidence include, but are not limited to:
- An invoice or receipt verifying purchases, repairs, etc.
- Sign-in sheets verifying attendance of staff at in-service training
- Interviews with more than one training participant about training
- Contact with resident council, e.g., when dignity issues are involved
Additionally, the revised policy articulates a course of action for certification based on the seriousness of noncompliance and the number of revisits that have already occurred.
What does this mean for my facility?
- Facilities are now no longer completely dependent on States to perform timely onsite visits. In some instances, they now have power to present evidence, thereby expediting their own verification of compliance.
- Verification of compliance is now on a continuum. The best-case scenario shows the latest correction date on a facility’s PoC to be the compliance date. Worst-case scenarios denote an onsite visit to establish that date.
- Two revisits are permitted for each certification cycle. The Regional Office must approve a third visit.
Common questions answered:
Q. If the facility requires a revisit and, on this revisit, new deficiencies are discovered, does a new certification cycle begin?
A. No, and the new tags are considered continuing non-compliance even if the old deficiencies are corrected.
Q. Are revisits required for removal of immediate jeopardy?
A. Yes.
Q. When substandard quality of care, actual harm, or immediate jeopardy is cited, and those tags are corrected by the time of the first revisit, must revisits continue to that facility until it achieves substantial compliance with any other tags that are at or above substandard quality care?
A. No.
Q. Does this policy apply to Medicaid as well as Medicare facilities?
A. The policy applies to Medicare-only, dually participating facilities, and State-operated facilities.
Q. Under the new guidance, when the new complaint survey is conducted under the State’s mandated time frames, will the complaint survey be considered as a revisit that will count toward the State’s 2-revisit count?
A. Initial complaint investigation visits, whether substantiated or not, are not counted toward the two revisits. However, when the complaint survey is conducted at the same time as the revisit, the revisit will count toward the revisit count.
Q. For purposes of a revisit count, are life safety code revisits counted separately from health revisits?
A. When the revisit is for the sole purpose of either the health or life safety survey, there are separate revisit counts toward each type. Otherwise, both are covered by the same revisit count.
Q. When the first revisit is only to determine if immediate jeopardy has been removed and is not a revisit on all deficiencies, does it count toward the revisit count?
A. Yes.
All information in this article is informational only and is not legal advice. Should you have any questions or a situation requiring advice, please contact an attorney.
Copyright 2004 by Garlo Ward, P.C., all rights reserved
Austin, Texas 78752-3714 USA
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