MDS Alert

Watch out: The significant changes that the Centers for Medicare & Medicaid Services (CMS) made to Exit Conference procedures earlier this year will now extend to Life Safety Code (LSC) rules.

On Aug. 19, CMS released a memo to state survey agencies (SAs) regarding revisions to the State Operations Manual (SOM), Appendix I. The memo addressed LSC surveyors specifically.

First, the memo announced revisions to Task 4 of Appendix I, which reinstated guidance that CMS inadvertently removed to LSC surveyors regarding the survey procedures for “Information Gathering.” CMS reinstated the omitted portion back into the SOM with no further changes to the guidance.

Second, CMS updated Appendix I with information regarding sharing deficiency tags during Exit Conferences. The revisions include reminders about Exit Conference procedures that CMS issued back in March 2016 (see “Your Survey Exit Conferences Just Got A Little More Vague,” MDS Alert Vol. 14, No. 4, page 37).

According to the latest memo, LSC surveyors aren’t allowed to make specific comments about your facility’s condition, but instead should use facts and cite problems that are in clear violation of regulatory requirements, stated the CMSCompliance Group Inc. (CMSCG) based in Melville, N.Y. (http://cmscompliancegroup.com/2016/08/23/som-appendix-i-lsc/).

What to expect: “Surveyors may not tell the provider that conditions/standards were not met,” CMSCG noted. “Surveyors are told to caution the facility that coding information is preliminary.”

Link: To read S&C: 16-35-LSC, “Revisions to the State Operations Manual (SOM), Appendix I,” go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-35.pdf.