CMS Issues S&C Related to Survey Exit Conferences

Nancy Leveille in Clinical & Quality

The information below was received from AHCA.

On March 11, 2016, CMS issued S&C: 16-11-ALL on the Subject: Exit Conferences - Sharing Specific Regulatory References or Tags which is attached. This was sent to State Survey Agency Directors on March 11, 2016 and was posted to the CMS website on March 22, 2016. The memo applies to all Medicare/Medicaid providers and suppliers regarding deficiencies found during the conduct of federal surveys and includes updates to the State Operations Manual Chapter 2 - The Certification Process, and Appendix P - Survey Protocol for Long Term Care.

The memo and materials emphasize "The Exit Conference during the onsite survey is both a courtesy to the provider and a way to expedite the provider's planning ahead of the formal receipt of the survey findings in the Form CMS-2567, State of Deficiencies." Specific tags are not to be provided and any discussion of possible areas of deficiency must include a statement that this is preliminary information and may change. The surveyors may not, under any circumstances, provide the scope and severity of a deficiency finding unless it is an immediate jeopardy.

The memo also states:  "For LSC surveys, the survey team may follow procedures for either non-LTC or LTC, depending on the degree to which, in the judgment of the team, the tag codes are important in helping the provider/supplier to understand the nature and location of the deficiency, and the corrective actions that would be necessary."

Finally, the memo specifies "States are not permitted to have blanket policies that differ from the policy described in this section. For example, States may not require surveyors to always provide certain information during the Exit conference."


Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20