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Long Term Care Survey and Certification

State licensure is mandatory
Federal certification as Medicare/Medicaid provider is voluntary


Onsite Surveys

Initial certification - to qualify for a provider agreement to participate in Medicare and/or Medicaid reimbursement.  Requires onsite Health and Life Safety Code surveys.  The onsite Health certification survey is conducted after facility has been licensed (if applicable) to operate as a health care provider and has admitted residents.  When facility is prepared to demonstrate compliance with the federal requirements, they forward a written request for an onsite certification survey.  Unannounced onsite Health survey is generally conducted within three (3) weeks of receipt of the facility’s assurance statement and request.

Provider agreement:  The earliest date a provider agreement can be effective is when the facility is in substantial compliance with the federal Health and Life Safety Code program requirements.  The state survey agency, per Virginia’s contractual agreement with the Health Care Financing Administration (HCFA), determines the effective date of provider compliance with program requirements.  This information is forwarded to HCFA for Medicare certification and the state Medicaid agency for Medicaid certification.

Recertification - to retain certification:  Facility must routinely demonstrate compliance with federal LTC Medicare/Medicaid program requirements.  This process includes the unannounced standard health survey (conducted by survey staff) and the Life Safety Code Survey (conducted by the State Fire Marshal’s Office, per agreement with VDH), abbreviated standard surveys (conducted by survey staff), and revisits surveys.

Standard health survey:  Full onsite survey.  To be conducted within 15 months of the facility’s previous standard health survey.  Could be as early as 9 months after the facility’s previous standard health survey, if needed, due to concerns about quality of care.  The state survey agency must maintain a statewide average of 12 months for all LTC Medicare/Medicaid recertification standard health surveys.  May include investigation of pending complaints.

Abbreviated health survey:  Focused onsite survey.  May be for the investigation of complaints or to determine facility status after a Change in Ownership/Operator.

Revisit survey:  Onsite survey.  To determine facility’s correction of previously cited deficiencies.  May include investigation of pending complaints.

  • Guidelines for certification procedures are established in the Health Care Financing Administration’s (HCFA) State Operations Manual (SOM).  The specific survey protocols for Long Term Care are found in Appendix P.        

Survey Outcomes

Compliance: 

The facility is in compliance with the program requirements if there are no deficiencies. 

The facility is in substantial compliance with the program requirements if there is no deficiency more serious than ‘potential for causing no more than a minor negative impact on the resident(s)’.  [LTC Scope/Severity Grid = “A”-“C”]

Noncompliance – opens a six (6) months “enforcement track”:

The onsite survey determined the facility has deficiencies more serious than ‘potential for causing no more than a minor negative impact on the resident(s)’.

If none of the deficiencies were more serious than ‘no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident’s ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services’  [Scope/Severity Grid = “D”-“F”, with no Substandard Quality of Care]:

State survey agency can (in the absence of receipt of serious or several complaints) “presume compliance” based on an acceptable plan of correction and credible evidence that the plan of correction has been fully implemented.

If any deficiencies resulted in a ‘negative outcome that has compromised the resident’s ability to maintain and/or reach his/her highest practicable physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services [Scope/Severity Grid = “G”-“I”] and/or ‘immediate jeopardy, a situation in which immediate corrective action is necessary because the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility’ [Scope/Severity Grid = “J”-“L”]

State survey agency must conduct an onsite revisit to determine the facility’s compliance with the program requirements.

Substandard Quality of Care (SQC):

any deficiency in 42 CFR 483.13, Resident Behavior and Facility Practices, 42 CFR 483.15, Quality of Life, or 42 CFR 483.25, Quality of Care, that constitutes immediate jeopardy to resident health or safety [Scope/Severity Grid = “J”-“L”]; or, a pattern of or widespread actual harm that is not immediate jeopardy {Scope/Severity = “H”-“I”]; or a widespread potential for more than minimal harm that is not immediate jeopardy, with no actual harm [Scope/Severity Grid = “F”].

Federal Enforcement Remedies

The state survey agency determines the facility’s compliance with the program requirements and forwards the survey outcome information to HCFA and/or the state Medicaid agency.  Certification remedies are not imposed by the state survey agency.  Remedies are imposed by HCFA (for Medicare only or Medicare/Medicaid facility) or the state Medicaid agency (for Medicaid only facility).  Selection of remedies is dependent upon the severity of the deficiencies found during an onsite survey.  Remedy options are

Category 1

  • Directed Plan of Correction
  • State Monitoring and/or
  • Directed Inservice Training

Category 2

  • Denial of Payment for New Admissions
  • Denial of Payment for All Individuals imposed by HCFA; and/or
  • Civil money penalties:  $50 - $3000/day
  • Single instance:  $1,000 - $10,000

Category 3

  • Temporary Management
  • Termination

Optional:

  • Civil money penalties
  • $3,050 - $10,000/day
  • Single instance:  $1,000 - $10,000

Denial of payment for new admissions must be imposed when a facility is not in substantial compliance within 3 months after being found out of compliance (Mandatory, per federal statute).

Denial of payment and State monitoring must be imposed when a facility has been found to have provided substandard quality of care on three consecutive standard surveys.

Termination of provider agreement must be imposed when a facility is not in substantial compliance within 6 months after being found out of compliance (Mandatory, per federal statute).

Substandard Quality of Care (SQC):  A finding of SQC will:

  1. be reported by the state survey agency to the state Ombudsman and the Board responsible for licensing the facility’s administrator, and
  2. result in the loss of the facility’s Certified Nurse Aide training program (if the facility has an approved program).

Effective 01/14/00:   If current survey results in finding(s) of “actual harm” and facility had “actual harm” deficiencies on their previous standard survey or any intervening survey, the facility will have “no opportunity to correct” prior to the imposition of certain remedies.


Last Updated: 06-13-2013

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