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Q: What is a condition-level survey deficiency?

Homecare Insider, July 29, 2013

Q: What is a condition-level survey deficiency?

A:  Condition-level deficiencies are the most serious type of deficiency cited by state agencies’ (SA) and are issued if a surveyor determines that a home health agency (HHA) is not in compliance with a CoP. Even one condition-level deficiency is enough to render an HHA out of compliance with the CoPs. In such a case, the surveyor must provide the HHA with a form that includes a statement of deficiencies section, which documents evidence to support the citation, and a plan of correction (POC) section, which HHAs are encouraged to use in setting out their POC. HHAs must respond with a POC within 10 calendar days of receiving the form.

For those HHAs that are cited with one or more condition-level deficiencies, compliance may not be certified by a surveyor based solely on a submitted POC. Instead, CMS places the HHA on a 90-day termination track (or a 23-day track for immediate jeopardy citations), in which the HHA must submit an allegation of compliance and actually achieve compliance or acceptable progress within 90 days in order to continue participating in Medicare.

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