Exit Conference

7203.3.1 – Exit Conference (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) The general objective of the exit conference is to inform the facility of the survey team’s observations and preliminary findings. The exit conference is a courtesy to the facility to provide the preliminary findings of the surveyors so that the facility can take swift corrective action to address any deficiencies. Surveyors must indicate that all findings are preliminary and are subject to supervisory review by the State and/or CMS Location. Deficiency citations are not final, and the CMS-2567 must not be given to the facility until after the State and/or CMS Location conduct a supervisory review and the report is finalized. Conduct the exit conference with facility personnel. Ask the Administrator to invite the Medical Director to the exit conference. Invite the ombudsman and an officer of the organized resident group (e.g., resident council), if one exists, to the exit conference. Also, invite one or two residents to attend. If the ombudsman, officer of the resident group, or residents cannot attend in-person, they should be allowed to attend virtually via conference call or video conferencing. The team may provide an abbreviated exit conference specifically for residents after completion of the normal facility exit conference. If two exit conferences are held, notify the ombudsman and invite the ombudsman to attend either or both conferences. It is important to provide clear information on the facility's noncompliance so the facility can develop an appropriate plan of correction. If the provider asks for the regulatory basis or the specific deficiency tag, the surveyors should generally provide it (except as noted below), but always caution that such coding classifications are preliminary and are provided only to help the provider gain more insight into the compliance issues identified during the survey through the interpretive guidance at the related tag. If the survey team is still deliberating as to which tags will be cited, the survey team should not speculate at the exit conference as to the specific tag coding that will be applied. For example, the team may still be deliberating as to whether a finding was a care planning deficiency or staff training deficiency. Similarly, the team may believe that additional consultation should occur with other State personnel (e.g., a pharmacist) before a specific tag number is assigned to the deficiency finding. In these cases, the survey team should describe the general area of noncompliance without identifying a specific tag code. This is a judgment to be the made by the survey team onsite. So, in preparation for the exit conference the team should deliberate as to the degree of detail that will be appropriate. Surveyors must not provide the Scope and Severity level of a given deficiency finding (unless it is an immediate jeopardy), as such levels of detail should await supervisory review. Instead, survey teams may describe the general seriousness (e.g., harm) or urgency that, in the preliminary view of the survey team, a particular deficiency may pose to the well-being of residents. This is a survey-specific decision based on the evidence gathered. As described below, states must follow the federal survey process. State licensure laws do not override the procedures outlined in the federal process. If a provider asks whether the noncompliance is isolated, a pattern, or widespread, the surveyor should respond with the facts (i.e., noncompliance was found affecting X number of residents). Surveyors should not make general statements such as, “Overall the facility is very good.” Surveyors should also not assume intent for noncompliance or assign blame to the facility or individual staff. Also, surveyors should not provide consultation, such as explaining how the facility can be compliant. Only discuss the facts. Do not rank requirements. Treat requirements as equally as possible. Cite problems that clearly violate regulatory requirements. The survey team must not discuss survey results in a manner that reveals the identity of an individual resident. After describing the team’s preliminary deficiency findings to the facility, let the facility know they will receive an official report of the survey which will contain any deficiencies that have been cited following supervisory review (Form CMS-2567, Statement of Deficiencies). If your state provides the sample list during the exit, follow instructions in the LTCSP Procedure Guide. If an extended survey is required and the survey team cannot complete all or part of the extended survey prior to the exit conference, inform the facility Administrator that the deficiencies, as discussed in the conference, may be amended upon completion of the extended survey. (See Chapter 2 for additional information concerning exit conferences.) During the exit conference, provide the facility with the opportunity to discuss and supply additional information that they believe is pertinent to the identified findings. Because of the ongoing dialogue between surveyors and facility staff during the survey, there should be few instances where the facility is not aware of surveyor concerns or has not had an opportunity to present additional information prior to the exit conference.