Federal Monitoring Surveys - Definition and Purpose

4157 - Federal Monitoring Surveys - Definition and Purpose (Rev. 1, 05-21-04) 4157A - Definition (Rev. 1, 05-21-04) A Federal Monitoring Survey (FMS) is a survey performed by the RO or designated contractors under the authority of the Central or Regional Offices, of any Medicare/Medicaid participating provider and/or supplier (see Chapter 6 for Labs). 4157B - Purpose (Rev. 1, 05-21-04) The RO conducts the survey to: ● Monitor SA performance in interpreting and applying Federal standards; ● Identify training and/or technical assistance needs of surveyors; ● Identify problems that surveyors and/or providers encounter in implementing Federal regulations; and ● Require correction of problems that exist in individual facilities or in individual surveys. 4157C - Scope of Survey (Rev. 96, Issued, 12-13-13, Effective: 12-13-13, Implementation: 12-13-13) 1. Full Survey A survey of all applicable CoPs and standards for all types of Medicare/Medicaid providers and/or suppliers except SNFs, NFs and ICFs/IID. SNFs, NFs are described separately in 3 below, and ICFs/IID are described separately in 4 below. 2. Partial Survey A survey of selected Conditions and/or standards for any type of Medicare/Medicaid provider and/or supplier, except SNFs and/or NFs and ICFs/IID. SNFs and/or NFs are described separately in 3 below, and ICFs/IID are described separately in 4 below. 3. SNF and/or NF Surveys a. Standard Survey - A standard survey is composed of Tasks 1-7, and is a resident-centered, outcome-oriented inspection which relies on a case-mix stratified sample of residents to gather information about the facility’s compliance with participation requirements. Based on the specific procedures detailed in Appendix P, a standard survey assesses: ● Compliance with residents’ rights and quality of life requirements; ● The accuracy of residents’ comprehensive assessments and the adequacy of care plans based on these assessments; ● The quality of services furnished, as measured by indicators of medical, nursing, rehabilitative care and drug therapy, dietary and nutrition services, activities and social participation, sanitation and infection control; and ● The effectiveness of the physical environment to empower residents, accommodate resident needs, and maintain resident safety. If in conducting the information gathering tasks of the standard survey the RO identifies a possible noncompliant situation related to any requirement, it investigates the situation to determine whether the facility is in compliance with the requirements. b. Extended Survey - The extended survey is conducted after substandard quality of care is found during a standard survey. When, based on performing the resident- centered tasks of the standard survey the RO makes a determination that the facility has provided substandard quality of care in 42 CFR 483.13, Resident Behavior and Facility Practices; 42 CFR 483.15, Quality of Life; and/or 42 CFR 483.25, Quality of Care, then an extended survey must be conducted within 14 days after completion of a standard survey. (See Appendix P, Part I, Section III, the extended and partial extended survey.) c. Partial Extended Survey - A partial extended survey is always conducted after substandard quality of care is found during an abbreviated standard survey. When, based on performing the abbreviated standard survey, the RO makes a determination that the facility has provided substandard quality of care in 42 CFR 483.13, Resident Behavior and Facility Practices; 42 CFR 483.15, Quality of Life; and/or 42 CFR 483.25, Quality of Care, it must conduct a partial extended survey. (See Appendix P, Part I, Section III, the extended and partial extended survey.) 4. ICF/IID Surveys a. Fundamental Survey - Conducted to determine the quality of services and supports received by individuals, as measured by outcomes for individuals and essential components of a system which must be present for the outcomes of active treatment to occur. Certain requirements are designated as fundamental and are reviewed first. The remaining requirements (that are not designated as fundamental) are supporting structures or processes that the facility must implement. A decision that a provider is in compliance with the fundamental requirements indicates an outcome-reviewed compliance with the non- fundamental requirements and associated Conditions of Participation. (Reference Transmittal No. 278 for specific tag numbers included primarily under 42 CFR 483.420, Client Protections, 42 CFR 483.440, Active Treatment Services, 42 CFR 483.450, Client Behavior and Facility Practices, 42 CFR 483.460, Health Care Services). b. Extended Survey - Conducted when standard-level deficiencies are found during the fundamental survey and the survey team has determined or suspects that one or more CoP examined during the fundamental survey are “not met.” The team needs to gather additional information in order to identify the structural and process requirements that are “not met” and to support their condition-level compliance decision. The team reviews all of the requirements within the CoP(s) for which compliance is in doubt. c. Full Survey - A survey of all applicable CoPs and standards. A full survey is conducted by the State Agency at an initial survey and at the discretion of the RO, based on the RO’s identification of concerns related to the provider’s capacity to furnish adequate services. 4157D - Survey Definitions (Rev. 1, 05-21-04) 1. Comparative Survey A Federal survey conducted within 60 days of the State survey to assess SA performance in the interpretation, application, and enforcement of Federal requirements. Whenever possible, the RO conducts comparative surveys within 30 days of the State survey. 2. Direct/Federal Jurisdictional Survey A Federal survey to assess provider performance and to determine whether a provider/supplier meets all applicable program requirements. It is used as the basis for approving a provider where the SA lacks jurisdiction. Federal personnel conduct surveys of health facilities of the Indian Health Services, Commonwealth of the Virgin Islands, and participating ESRD facilities in VA hospitals. 3. Validation Survey for Accredited Facilities A survey of an accredited entity, e.g., hospital, HHA, ASC, to validate the presumed compliance of the entity’s deemed status and the survey process of the accrediting organization, recognized by CMS. 4. - Validation Survey of SNFs or NFs An on-site survey of a representative sample of SNFs or NFs in each State (at least 5 percent of the number of SNFs and NFs surveyed by the State in the year, but in no case less than 5 SNFs and NFs in the State) within 2 months of the date of a State’s standard or an extended survey. The sample is of a sufficient size to allow inferences about the adequacy of the State’s surveys, and, in conducting a validation survey of SNFs and NFs, CMS uses the same survey protocols the State used. 5. Federal Oversight Support Survey (FOSS) An on-site SNF/NF survey where the Federal surveyor(s) attends the State survey (initial, recertification, revisit and/or complaint) to observe and assess State surveyor team performance. The RO surveyor(s) may provide training and/or technical assistance to address identified performance needs while on-site as a result of the evaluation of outcomes. The outcomes include: ● Concern Identification ● Sample Selection ● General Investigation ● Kitchen and Food Service Investigation ● Medication Investigation ● Deficiency determination The Form CMS-2567 is also evaluated to identify whether deficient practices identified on-site are reflected in the Form CMS-2567.