Michigan Department of Community Health Bureau of Health Systems Mike Pemble Director Joint Provider Surveyor Training September 14, 2010

 Complaint Backlog Status  Enforcement Cycles

Revisits  No guarantee of revisit.  A facility is not “entitled” to any revisits; revisits are performed at the discretion of CMS or the State. Source: Section 7317B State Operations Manual

Choosing a Plan of Correction Date  Pick the earliest date possible  Make certain compliance is achieved by that date  Expect a revisit anytime after the latest alleged compliance date on the approved Plan of Correction.  Timing of the revisit may be impacted by a 7–10 day time allowance in order for the facility to show it is able to maintain compliance, and due to other survey priorities of the State Agency.  If multiple survey events have occurred in the survey cycle, the State Agency will often consolidate and conduct multiple revisits on the same date.

Number of Revisits  Two revisits are permitted, at the State’s discretion, without prior approval from the regional office; a third revisit may be approved only at the discretion of the regional office. Regional offices are limited to approving only this one additional revisit. Source: Section 7317B State Operations Manual

CMS Revisit Policy: Compliance Dates  1st Revisit: If the State Agency determines the facility has corrected all outstanding deficiencies at the first revisit, compliance is certified as of the latest correction date on the approved Plan of Correction, unless there is evidence of noncompliance after that date.  2nd Revisit: If the State Agency determines the facility has corrected all outstanding deficiencies at the second revisit, the compliance date is certified as of the date of the second revisit, unless acceptable evidence independently determines compliance at an earlier date.

CMS Revisit Policy: Compliance Dates  3rd Revisit: If the State Agency determines the facility has corrected all outstanding deficiencies at the third revisit, the compliance date is certified as of the date of the third revisit.  4th Revisit: If the State Agency determines the facility has corrected all outstanding deficiencies at the fourth revisit, the compliance date is certified as of the date of the fourth revisit

Direct Observation of Compliance  Direct observations are often performed in addition to record review and interview to verify that compliance has been achieved.  Examples of direct observations include, but are not limited to, observations of care and services provided to residents, such as wound care, medication pass, transfers, bathing, food preparation, meal service or dining assistance

Acceptable Evidence (2 nd Revisit)  The CMS revisit policy allows an exception for establishing a compliance date earlier than the date of the second revisit where acceptable evidence may independently verify compliance and direct observation is determined to be unnecessary.  Some examples of potential situations include, but may not be limited to:  Sign-in sheets verifying attendance of staff at in-service trainings.  Interviews with training participants about the content of training.  Interview with resident council members, other residents and/or family members to confirm that an issue has been resolved.  Review of sample residents’ clinical documentation independently verifies that a deficiency was corrected.  An invoice or receipt that shows needed purchases or repairs have been made.