June 08, 2005

CMS Instructs State Survey Agencies On Compliance Dates

A State or two in Region VI appear to be confused about what compliance date to assign when a facility clears on a revisit. Thus, CMS sent a recent Regional Survey And Certification Letter to all State Survey Agencies to clarify the issue. Click here to see the letter.

It is suspected that the letter was prompted by a conversation between CMS and the unamed State Survey agencies that went something like this:

"If you find deficiencies on an initial or annual visit, you are to send the facility the 2567 by the tenth business day after you exit the facility. Got it little buddy?"

"Got it Skipper. After the exit, I am to leave the facility and then to get the 2567 back to them within 65 days."

"No! No! No! You are to get the 2567 back to them within 10 business days."

"Okay. Okay. I've got it. I am to wait until 10 days before DPNA goes into effect to get them the 2567."


"Let's go on to something else for the moment. If the facility clears on the first revisit, you are to assign the compliance date as the date the facility says it corrected if the facility provides documentation to verify continued compliance after correction was achieved. If the facility has no correction-monitoring data--but is in compliance--the correction date will be the last date on the plan of correction submitted by the facility. Understand?"


"If the facility clears on the second revisit and the facility has collected data showing correction and verifying continued compliance--the date proven by that data is to be the compliance date. If they have no data, the date of the revisit is the compliance date."

"I think I get it! When we go back in after the initial survey, if the facility clears--the compliance date is the date of our revisit. Right, Skipper?"


("What did I do to deserve this?")


If you have a bad survey, it is important that you:

  • Thoroughly document what you actually did to correct--not just your plan,
  • Collect monitoring data that will prove that the correction was effective. (e.g. collect data demonstrating that your staff is doing things correctly and demonstrating competency)
  • Record the monitoring data in an understandable way so that you can prove to the re-survey team that compliance was achieved on your preferred date.
  • Have this data handy for the revisit
If you live in the unamed State(s) that are not getting your 2567 to you in a timely manner and causing you to go into DPNA because of insufficent time to get things together:

  • Begin your correction the second the surveyors exit.
  • Consider writing letters to CMS documenting the violations of procedure
  • Contact your attorney for assistence.