In order to receive payments and remain certified under the Medicare and Medicaid programs all skilled nursing facilities (SNF’s) are required to undergo a health inspection in the form of an unannounced standard survey by a professional surveyor at least every 15 months, and if there are areas of noncompliance a revisit survey or extended survey may be conducted. In addition, surveyors may also conduct ad hoc complaint surveys, which are surveys carried out in response to specific complaints made about a SNF.
The purpose of surveys is to identify actual or potential areas of noncompliance with relevant federal healthcare rules and regulations. In order to avoid penalties for noncompliance SNF’s must be in substantial compliance not only with Medicare and Medicaid requirements, but also with relevant state laws.
If a surveyor finds an area of noncompliance during a survey he/she will classify the violation according to a federal “F-Tag” numbering system, so-called because SNF regulations are set forth in subsection F of the federal regulations governing SNF’s. Each F-Tag corresponds to a particular long-term care facility regulation.
An instance of noncompliance is also known as a “deficiency,” and for each deficiency discovered the surveyor must assign it an alphabetical letter based on how serious it is. In order to assign the deficiency a letter the surveyor will first determine the level of harm caused by the deficiency to the SNF resident(s). This determination is referred to as the “severity” of the deficiency. Then, the surveyor will determine whether the scope of the deficiency is isolated, fits a pattern, or is widespread. Finally, based on the severity and scope of the deficiency the surveyor will assign it an alphabetical letter on a scale of A through L, with “A” being the least serious and “L” being the most serious.
If during the course of a standard or revisit survey the surveyor finds that a particular SNF’s noncompliance is so severe that it constitutes what’s known as “substandard quality of care” (SQC), then the surveyor will inform the SNF administrator that an extended (or partial extended) survey must be conducted.
A SQC is any deficiency found in 42 CFR relating to Resident Behavior and Facility Practices, Quality of Life, or Quality of Care if such deficiency constitutes an “immediate jeopardy” to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or where there is no actual harm but a widespread potential for more than minimal harm that is not immediate jeopardy.
Immediate jeopardy is defined as “A situation in which 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” (See 42 CFR Part 489.3). When such circumstances exist, immediate corrective action must be taken not only to avoid harm to SNF residents, but also to avoid severe penalties for noncompliance.
There are three components that surveyors take into consideration when deciding whether circumstances warrant issuing a citation of immediate jeopardy: harm, immediacy, and culpability.
Harm can be distinguished between actual harm and potential harm. Actual harm is where a SNF’s deficiencies caused serious harm, injury, impairment, or death of a resident. Potential harm is a situation where a SNF’s deficiencies pose the potential to cause serious harm, injury, impairment, or death to a resident.
The immediacy component of an immediate jeopardy determination refers to whether the actual or potential harm is likely to happen in the near future if immediate action is not taken.
Finally, the culpability component of an immediate jeopardy determination considers the extent to which a SNF knew of the actual or potential harm, and if so whether the SNF investigated the matter and took corrective measures to address it. Finally, if corrective measures were taken the culpability component looks at whether the SNF later evaluated the corrective measures to determine whether they were effective.
If a surveyor does find that circumstances warrant a finding of immediate jeopardy the consequences can be severe. Immediate jeopardy citations typically result in a fine known as a “Civil Monetary Penalty” which ranges from $3,050 per day to $10,000 per day and may be imposed retroactively to the date of the incident.
In addition, the facility only has 23 days to resolve the immediate jeopardy situation. If a surveyor conducts a revisit survey and the situation hasn’t been addressed by that time Medicaid termination will go into effect.
Given the severity of the financial consequences to SNF’s that are found to be in immediate jeopardy it’s crucial to stay in compliance with healthcare rules and regulations. Clearpol’s Policies.ai software can help SNF’s and other facilities stay on top of the ever-changing and complex healthcare regulatory landscape. Having robust healthcare compliance policies and procedures in place will not only protect the health of patients, but also stave off serious financial penalties.