The Centers for Medicare & Medicaid Services (CMS) has released the final version of the revised policies on the immediate imposition of federal remedies. The Quality, Safety & Oversight (QSO) memo 18-18-NH (formerly known as Survey & Certification, or S&C memo), replaces S&C: 16-31-NH, released in July 2016 and S&C: 18-01-NH, published in a draft on October 27, 2017. The October 2017 memo solicited comments on proposed revisions to the guidance requiring, for certain situations, the immediate imposition of federal remedies on Medicare and Medicaid participating skilled nursing facilities.

With this finalized version of the immediate imposition policies, CMS has revised guidance in Chapter 7 of the State Operations Manual (SOM) related to the Immediate Imposition of Federal Remedies as well as other associated sections of Chapter 7, as noted in QSO 18-18-NH. The revised guidance is effective July 15, 2018. We recommend that you read the new memo in its entirety.

CMS has made substantive revisions to the guidance released in July 2016. Changes include:

• When the current survey identifies Immediate Jeopardy (IJ) that does not result in serious injury, harm, impairment or death, the CMS Regional Office (RO) may determine the most appropriate remedy to immediately impose. This may include a civil money penalty (CMP); however, in these instances, CMPs are not required. A complete list of enforcement remedies can be found here.
• Any deficiency from the current survey at levels “G, H, or I” that constitutes Substandard Quality of Care (SQC) is subject to the immediate imposition of remedies, excluding level “F” SQC deficiencies where there was no actual harm.
• For Special Focus Facilities (SFF), scope/severity level “F” citations under tags F812, F813 or F814 are excluded from the immediate imposition of remedies.
• Past Noncompliance deficiencies (as described in §7510.1 of Ch. 7 of the State Operations Manual, i.e., Determining Citations of Past Noncompliance at the Time of the Current Survey) are not included in the criteria for Immediate Imposition of Remedies. 

Additional changes include clarifications about survey timelines related to the immediate imposition of remedies, the process for enforcement actions when IJ exists and when it does not exist, and clarifications regarding the selection of remedies. CMS reinforces in this policy that the purpose of federal remedies is to encourage facilities to promptly achieve and maintain compliance with federal requirements and that remedies should be selected that will best address the specific circumstances. CMS ROs are also advised to consider the extent to which the noncompliance is a one-time mistake or accident, the result of larger systemic concerns, or more intentional disregard for resident health and safety.

For questions related to this memo, please contact the DNH Triage Team at dnh_triageteam@cms.hhs.gov. 

AHCA Contact: Sara Rudow at srudow@ahca.org.