SA Conducting Unscheduled Surveys

2702 - SA Conducting Unscheduled Surveys (Rev. 1, 05-21-04) 2702A - Survey Due to Unanticipated Events (Rev. 1, 05-21-04) It may be necessary to conduct a complete survey at an earlier date than planned. Possible reasons for this include: • A complaint about deteriorating standards of care; • Results of a complaint validation survey of an accredited hospital/find CoP out of compliance; • Loss of hospital accreditation; • An employee strike; • Change of ownership or changes in managerial personnel; or • A significant change in the type of treatment provided. The decision to conduct a full survey at an earlier date than originally planned depends upon whether there is a likelihood that the certification (or compliance) status could have changed. Do not announce such surveys. The SA should schedule subsequent surveys based upon the date of this survey. (See §7205 for SNF/NF.) 2702B - Change of Size or Location of Provider Institution (Rev. 1, 05-21-04) Changes of size or location do not ordinarily require a special survey. The provider is expected to continue to uphold the standards of operation detailed in the most recent survey. Only if the relocation raises significant questions as to the provider’s ability to maintain standards is a resurvey necessary. However, there may be situations where the relocation is so far removed from the ordinary approved site that you conclude that this is a different provider/supplier, e.g., different employees, services and patients. In such cases, it may be that the relocation constitutes a cessation of business at the providers old location and a voluntary termination on the part of the provider. Such situations should be discussed immediately with the CMS RO. In deciding whether to advance the resurvey, the SA considers the recentness of the last survey, licensure information concerning the new arrangement, and whether a phone contact for indicated information (e.g., staffing changes) will suffice to resolve questions. The fact that a new site/building is not shown on the most recent LSC survey report does not automatically require the date of the full scheduled resurvey to be advanced. However, the SA should ensure that the new location meets the applicable physical environment and LSC requirements. (See §§3202 and 3204.)