Long-Term Care Survey Alert

Published on Tue Jun 28, 2005 PDF

Question: Can surveyors re-cite a facility for the same problem that the facility is addressing in its plan of correction before the deadline for correction? If so, under what circumstances?

Answer: Yes, one does occasionally see surveyors recite a facility in such a scenario, but usually only for serious deficiencies.

One scenario: A serious event occurs during the corrective period. Say a facility has an elopement cited at F324 on Jan. 1. The plan of correction (POC) says all inservices and other corrective actions will be completed by Feb. 1, and there is another incident (any kind of accident) that happens on Jan. 25. Obviously, surveyors can cite that incident, regardless of whether it's another elopement.

A more problematic situation might be when surveyors cite one example of noncompliance on Jan. 1 and then later cite another instance that existed during the original survey. The Centers for Medicare & Medicaid Services will argue that a surveyor is under no obligation to cite everything she sees at the time of a survey - and that a deficiency is a deficiency. As a practical matter, if the noncompliance persists through the second citation date, the facility may have a problem demonstrating the effectiveness of its corrective action.

Thus, from a survey/enforcement management perspective, a facility should make its corrective period as short as possible (consistent with actually fixing a problem) because the potential for a remedy runs at least until correction. If the second citation is a G or above, the facility will likely receive a civil monetary penalty.

Source: Joseph Bianculli, JD
Arlington, VA