Entrance Conference - Non-Long Term Care

5079 – Entrance Conference - Non-Long Term Care Providers/Suppliers (Rev. 120, Issued: 09-19-14, Effective: 09-19-14, Implementation: 09-19-14) Onsite complaint investigations must always be unannounced. Upon entrance, advise the provider/supplier CEO or other senior official on duty of the general purpose of the visit. The SA explains the reason for the survey and avoids any impression that a predetermination has been made as to the validity of the allegation. It is important to let the facility know why you are there, but to also protect the confidentiality of those involved in the complaint. Do not release information that will cause opportunities to be lost for pertinent observations, interviews, and record reviews required for a thorough investigation. For example, in the case of a hospital, critical access hospital or ambulatory surgical center, if the complaint is that a patient developed a life-threatening infection in a post-surgical wound, do not tell the facility the exact complaint. Rather, tell them it is a situation related to infection control for surgical patients. Another example, in the case of a long term care facility, would be when a complaint that food that is intended to be served hot is always served cold. In this case, do not tell the provider the exact complaint. Rather, tell them it is a situation related to dietary requirements. (See Section 5300.2 for guidance on the entrance conference for long term care facilities as well as the provider/supplier-specific appendices of the SOM, and Appendix V of the SOM concerning EMTALA.)