Survey Process Notes: Tips From The Trenches

By Caralyn Davis, Staff Writer - March 21, 2018

The Long-term Care Survey Process (LTCSP) pulls some pieces from the traditional survey and some pieces from the Quality Indicator Survey, so few directors of nursing services (DNSs) will be completely surprised by how it works the first time they undergo an LTCSP survey. However, the new process does have a few unique twists all its own. Here are four tips from nurses who have seen an LTCSP survey in action first-hand:


Have your survey binder ready to go

When surveyors arrive in the facility for a standard survey, providers must be ready to deliver six specific sets of information by six different deadlines, according to the Entrance Conference Worksheet developed by the Centers for Medicare & Medicaid Services (CMS):

·         Immediately upon entrance,

·         At the entrance conference,

·         Within one hour of entrance,

·         Within four hours of entrance,

·         By the end of the first day of survey, and

·         Within 24 hours of entrance.

“Having the entrance information ready so that you don’t have to scurry around trying to compile it when the survey team comes in sets the tone for the survey,” says Carol Hill, MSN, RN, RAC-MT, DNS-CT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “You don’t want the surveyors to have to wait. You need to be able to provide the requested information within the appropriate time frames.”

Thirty-four of the 37 items on the Entrance Conference Worksheet list information, some of it quite detailed, that the facility needs to give the survey team. Rather than worry about what’s needed at each deadline, some DNSs have used a more proactive approach. “As soon as our survey window opened, I went through the Entrance Conference Worksheet and made sure my survey book (i.e., survey binder) had absolutely everything listed on that worksheet, including the facility assessment, the QAPI plan, and the emergency preparedness plan,” says Wendy Decknatel, RN, director of nursing services at Parkview Home in Belview, MN.

“Then I updated my book weekly, so when the surveyors came in, they had all of the information they needed within half an hour of arriving,” explains Decknatel. “The survey team said it shortened up the survey quite a bit because they didn’t have to ask for anything. I had it all ready and just gave it to them.”

Note: Download the zip file here containing the Entrance Conference Worksheet, including its two worksheets, Beneficiary Notice - Residents Discharged Within the Last Six Months and Electronic Health Record (EHR) Information, as well as the SNF Beneficiary Protection Notification Review (form CMS-20052). Download the Matrix for Providers With Instructions here.

In addition, DNSs should have a plan in place to provide surveyors with the required information during off-hours, says Hill. “Survey teams aren’t limited to the day shift. Sometimes they come in late at night or early in the morning, and someone on staff needs to know what to do if the surveyors arrive and where to find the information they will request when you and other members of the management team aren’t there.”


Be ready for surveyors to be out and about

In the new LTCSP, the surveyors are out on the floor so much more, interacting with the residents and the staff, says Hill. “That’s a little bit different for everyone, so it’s important for providers to prepare.”

“During the whole time the surveyors were here in our facility, they were out on the floor,” agrees Decknatel. “In the past, they were out on the floor during the first phase, and then they sat at their computers in the conference room and were very seldom on the floor. This time, they were out on the floor talking to staff, talking to residents, and observing throughout the entire survey.”

Surveyors not only spend much more time on the floor, they are also designated to specific areas of the facility, says Hill. “In previous surveys, surveyors often did a lot of going back and forth between residents in various locations. However, now they spend most of their time in a focused section of your building where they are assigned, so it is easier for them to pick up on potential care and quality issues.”

For example, a surveyor could be present on the floor to witness previously known difficult or even dangerous behaviors of a resident with dementia, or a surveyor could notice that a resident who has had multiple skin tears doesn’t have Geri-Sleeves in place when they are on the care plan, points out Hill. “There is just more opportunity for exposure with the survey team spending so much time on the floor with a specific group of residents.”

So DNSs should make sure that the care plans match the residents, says Hill. “Your interdisciplinary team should be reviewing the care plans with each MDS and keeping them current based on the status of the resident. For example, if a resident gets an order for oxygen or a psychotropic medication, that needs to be added to the care plan. In addition, you have to make sure that your documentation matches the residents too. The documentation should paint the same picture that the surveyors will see through observations and interviews with staff.”


Don’t expect as much direct surveyor feedback

In the LTCSP, surveyors will ask managers for information they can’t find, says Theresa Poole, RN, vice president of clinical services for Christian Horizons in St. Louis, MO. “For example, a surveyor might say, ‘I’m not finding this siderail assessment. Can you let me know if you really have one or not?’”

However, there are no daily exit interviews, notes Poole. “As managers, you get very little feedback throughout the survey. You can tell the general direction the survey team is headed by the policies or assessments they ask for, but there doesn’t seem to be a direct opportunity for management to learn what they’re thinking and present a rebuttal or additional information to support your interdisciplinary team’s work as the survey progresses.”

Note: CMS expects facility management to obtain additional information about how the survey is going from their staff. In the final version of the PowerPoint presentation Overview of the New Long-term Care Survey Process, CMS offers this advice: “Staff are encouraged to report surveyors' questions/concerns to their supervisors.”

Like previous surveys, the LTCSP does include an exit conference, which is supposed to be “conducted in the same manner as previous surveys,” says CMS in the Overview presentation. However, providers have experienced a few surprises. In some facilities, surveyors actually failed to hold a final exit conference, walking out of the building without a word on the last day.

In other facilities, the exit conference seems to be much more generalized than in previous surveys. “There’s not a strong sense of closure to the survey until you get your 2567. For example, surveyors in some states used to explain exactly which F-tags were probably going to be cited. That helped you to get a head start on your plan of correction and your action items,” points out Poole. “So far with the new survey process, the feedback is more limited. At least in some states, the surveyors don’t give you anything firm: There is no listing of concerns. In other states, there is a listing of concerns, but not detailed by F-tag.”

The following excerpt from the LTCSP Procedure Guide describes how the survey team should conduct exit conferences:

Step 24: Exit Conference with Facility


· Conduct an exit conference with the facility administration/leadership to inform the facility of the survey team’s observations and preliminary findings.

· Invite the ombudsman and an officer of the organized residents group, if one exists, to the exit conference. Also, invite one or two residents to attend. 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.

· Do not discuss survey results in a manner that reveals the identity of an individual resident. Provide information in a manner that is understandable to those present, e.g., say the deficiency “relates to development of pressure ulcers,” not “Tag F686.”

· Describe the team’s preliminary deficiency findings to the facility and let them know they will receive a report of the survey which will contain any deficiencies that have been cited (Form CMS-2567).

· 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 Administrator that the deficiencies, as discussed in the conference, may be amended upon completion of the extended survey.

· 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.

· If your state provides the sample list during the exit, click the Reports icon; select the “Sample List Provided to Facility” report; click Run Reports and then send the report in a secure method electronically OR print the report. States may also elect to send the Sample List with the CMS-2567.


Expect occasional process deviations

“Like providers, surveyors are still learning the LTCSP. So survey may not always follow the LTCSP Procedure Guide step by step,” stresses Poole. “For example, we had one survey where the team didn’t go to the floor immediately. Instead, they first went to the conference room for several hours. It was a little bit of a different routine than the other LTCSP surveys we’ve had.”


For permission to use or reproduce this article in full or in part, please submit a permissions form

Add New Comment