Survey Readiness and Management

Survey readiness is what happens every day that the surveyor does not step onto the floor, all in preparation for the day that he or she does. Be ready.Learn about all of the trends in the new Survey process, how to get ready for survey, manage it while the surveyors are in your facility, to responding to deficiencies. Check back here frequently for survey news!

  • Survey Readiness: Critical Element Pathways, Observations, Reviews, and Policy Calendar Tool

    By AADNS - December 04, 2019
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  • CMS Online Training: How to Develop an Antibiotic Stewardship Program (11/19)

    By CMS - November 27, 2019
    Class Description: To provide technical assistance to nursing home providers on the implementation of an Antibiotic Stewardship Program. Training goals include to support compliance with the requirements for an antibiotic stewardship program (ASP) and to improve appropriate antibiotic usage. Completion of the training does not automatically deem a provider compliant. This training supports compliance, but providers must still meet all components of the antibiotic stewardship requirements.
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  • LTCSP Survey Resources: Surveyor Tools (11/19)

    By CMS - November 25, 2019
    This ZIP file contains resources for surveyors conducting initial surveys under the Long-term Care Survey Process (LTCSP).
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  • LTCSP Procedure Guide - Updated (11/19)

    By CMS - November 25, 2019

    The LTCSP Procedure Guide provides instruction on the procedural and software steps necessary for completing the Long-term Care Survey Process. Surveyors use the Procedure Guide for all standard surveys of SNFs and NFs, whether freestanding, distinct parts, or dually participating. The LTCSP steps are organized into seven parts: 1) offsite preparation; 2) facility entrance; 3) initial pool process; 4) sample selection; 5) investigation; 6) ongoing and other survey activities; and 7) potential citations. Below is a broad overview of the key onsite parts of the LTCSP (parts 3 – 7).

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  • Top Ten Citations Part Two – Deep Dive into F812 and F656

    By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - November 13, 2019

    Last month, we provided members with a list of the top ten federal deficiencies since January of 2019. As a reminder, the top ten deficiencies are:

    1. F880 - Infection prevention and control

    2. F689 - Free of accidents, hazards/supervision/devices

    3. F812 - Food procurement/storage

    4. F656 - Develop/implement comprehensive care plan

    5. F684 - Quality of care

    6. F761 - Label/storage of drugs and biologicals

    7. F657 - Care plan timing and revision

    8. F758 - Free from unnecessary psychotropic med/prn use

    9. F677 - ADL care for dependent residents

    10. F550 - Resident rights

    (The citations above in red reflect the potential to cause substandard quality of care when a facility is cited at a scope and severity of F, H, I, J, K, or L level)


    This month, we will take a deeper dive into the number three and four top citations and explore common reasons that facilities are struggling to meet these regulations.

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  • Policy and Procedure Review and Development Guide Tool

    By AADNS - November 13, 2019
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  • Five-Star Technical User's Guide UPDATED AGAIN (10/19)

    By CMS - October 28, 2019

    CMS created the Five-Star (5-Star) Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them. Updated twice in October 2019.

    October 2019 Revisions

    In October 2019, several changes were made to the Nursing Home Compare website and the Five-Star Quality Rating System. These changes affected the health inspection and quality measure domains. This section provides details on these changes.

    Ratings changes for facilities that receive the abuse icon: To make it easier for consumers to identify facilities with instances of non-compliance related to abuse, starting in October 2019, CMS added an icon to highlight facilities that meet either of the following criteria: 

    1. Harm-level abuse citation in the most recent survey cycle: Facilities cited for abuse where residents were found to be harmed (Scope/Severity of G or higher) on the most recent standard survey or on a complaint survey within the past 12 months. 
    2. Repeat abuse citations: Facilities cited for abuse where residents were found to be potentially harmed (Scope/Severity of D or higher) on the most recent standard survey or on a complaint survey within the past 12 months and on the previous (i.e., second most recent) standard survey or on a complaint survey in the prior 12 months (i.e., from 13 to 24 months ago). 

    Nursing homes that receive the abuse icon have their health inspection rating capped at a maximum of two stars. Due to the methodology used to calculate the overall rating, the best overall quality rating a facility that receives the abuse icon can have is four stars. 

    Removal of quality measures related to pain: CMS removed two quality measures (QMs) from the Nursing Home Compare website and the Five-Star Quality Rating System in October 2019. These measures are: 

    • Percentage of short-stay residents who report moderate to severe pain. 
    • Percentage of long-stay residents who report moderate to severe pain. 

    As a result of dropping these two measures, the cut-points for the long-stay, short-stay, and overall QM ratings changed. These changes were made to maintain, as close as possible, the same distribution of short-stay and long-stay QM ratings as were posted on Nursing Home Compare in July 2019. 


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  • CMS Dementia Care Resources Webpage (10/19)

    By CMS - October 25, 2019

    CMS has established a Dementia Care Resources page to provide information that was previously housed at the National Nursing Home Quality Improvement Campaign. Additional resources are available through the QIO program.

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  • Infection Control in Healthcare Personnel Guidelines (Part I) - Updated (10/19)

    By CDC - October 23, 2019
    Preventing the transmission of infectious diseases among healthcare personnel (HCP) and patients is a critical component of safe healthcare delivery in all healthcare settings. Today, CDC published Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services, an update of four sections of Part I of the Guideline for infection control in health care personnel, 1998 (“1998 Guideline“) and their corresponding recommendations in Part II:

    ·  C. Infection Control Objectives for a Personnel Health Service

    ·  D. Elements of a Personnel Health Service for Infection Control

    ·  H. Emergency-Response Personnel

    ·  J. The Americans With Disabilities Act

    The updated recommendations are aimed at the leaders and staff of Occupational Health Services (OHS) and the administrators and leaders of healthcare organizations (HCO) and are intended to facilitate the provision of occupational infection prevention and control (IPC) services to HCP and prevent the spread of infections between HCP and others. Additional updates to the 1998 Guideline are underway and will be published in the future. Updates in Part I include: 

    ·  a broader range of elements necessary for providing occupational IPC services to HCP;

    ·  applicability to the wider range of healthcare settings where patient care is now delivered, including hospital-based, long-term care, and outpatient settings such as ambulatory and home healthcare; and

    ·  expanded guidance on policies and procedures for occupational IPC services and strategies for delivering occupational IPC services to HCP.

    New topics include:

    ·  administrative support and resource allocation for OHS by senior leaders and management,

    ·  service oversight by OHS leadership, and

    ·  use of performance measures to track occupational IPC services and guide quality improvement initiatives.  

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  • Oct. 24 CDC Call With Free CE: Preventing the Spread of Novel or Targeted Multidrug-resistant Organisms (MDROs) in Nursing Homes through Enhanced Barrier Precautions

    By CDC - October 23, 2019

    At the conclusion of the session, the participant will be able to accomplish the following:

    • Describe the burden of multidrug-resistant organisms (MDROs).
    • Describe challenges to preventing MDRO transmission in nursing homes.
    • Define Standard Precautions, Enhanced Barrier Precautions, and Contact Precautions.
    • Identify which residents and activities meet criteria for Enhanced Barrier Precautions.
    • Discuss best practices for implementing Enhanced Barrier Precautions.
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  • Trends in Nursing Home Complaints (2016-2018): OIG Interactive Map (10/19)

    By OIG - October 22, 2019
    The nursing home complaint process is a critical safeguard to protect vulnerable nursing home residents. The Centers for Medicare & Medicaid Services (CMS) relies upon each State's survey agency to respond to health and safety concerns raised by residents, their families, and nursing home staff. State agencies must investigate the most serious complaints on-site within certain timeframes. However, a previous Office of Inspector General (OIG) report found that a few States fell short in the timely investigation of the most serious nursing home complaints between 2011 and 2015. To complement this report, OIG published an interactive map that displays details on nursing home complaint trends between 2011 and 2015.

    The new interactive map below updates this information for years 2016 through 2018. Specifically, it displays details on nursing home complaint trends between 2016 and 2018 for each State, including the number of complaints received and the number of the most serious complaints that a State investigated late.

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  • HHS Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use (10/19)

    By US Department of Health and Human Services - October 15, 2019

    The U.S. Department of Health and Human Services published a new Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics - PDF. Individual patients, as well as the health of the public, benefit when opioids are prescribed only when the benefit of using opioids outweighs the risks.  But once a patient is on opioids for a prolonged duration, any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient. The HHS Guide provides advice to clinicians who are contemplating or initiating a change in opioid dosage.

    “Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

    Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. In certain situations, a reduced opioid dosage may be indicated, in joint consultation with the care team and the patient. HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.

    Compiled from published guidelines and practices endorsed in the peer-reviewed literature, the Guide covers important issues to consider when changing a patient’s chronic pain therapy. It lists issues to consider prior to making a change, which include shared decision-making with the patient; issues to consider when initiating the change; and issues to consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and provide behavioral health support. 

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  • MDS 3.0 Quality Measures (QM) User's Manual V12.1 Re-posted (10/19)

    By CMS - October 09, 2019

    Nursing Home Quality Measure Changes

     The following nursing home quality measures have been removed:

    ·        Percentage of short-stay residents who report moderate to severe pain.

    ·        Percentage of long-stay residents who report moderate to severe pain.

    This change supports the federal initiative to reduce opioid utilization by seeking to prevent a potential scenario where the performance of a facility on the pain quality measures may inappropriately contribute to their decision to seek the administration of an opioid. 

    MDS 3.0 QM User’s Manual Version 12.1 Now Available

    The MDS 3.0 QM User’s Manual Version 12.1 has been posted. The MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V12.1 can be found in the Downloads section of this page and the MDS 3.0 QM User’s Manual V12.0 has been moved to the Quality Measures Archive page.

    One file related to the MDS 3.0 QM User’s Manual has been posted:

    1.      MDS 3.0 QM User’s Manual V12.1 contains detailed specifications for the MDS 3.0 quality measures.

    2.      Quality Measure Identification Number by CMS Reporting Module Table V1.7 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module.  A unique CMS identification number is specified for each QM.

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  • How to Avoid Citations for the Top Two Most-Cited Deficiencies

    By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - October 08, 2019

    The survey process can be overwhelming. Surveyors arrive and begin evaluating whether the facility has met specific quality standards. Often, even the prospect of an impending survey leads to anxiety and fear for facility leaders and staff. Being aware of common citations and proactively putting plans in place to avoid those findings can help lessen the anxiety. Knowing the most-cited deficiencies and being survey ready at all times can help reduce the number of and lower the scope and severity of common citations.


    Over the years, the top ten survey deficiencies have remained relatively constant, but the reasons that facilities receive a specific citation do vary across the country. Let’s look at the most-cited deficiencies across the nation since January 2019 and delve further into common reasons for the top two citations.

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  • CMS QSO Memos Explain New Five-Star Changes (10/19)

    By CMS - October 08, 2019

    Updates to the Nursing Home Compare website and the Five Star Quality Rating System

    Memo #QSO-20-02-NH

    Posting Date 2019-10-07

    Fiscal Year 2020


    • CMS is removing the quality measures related to residents’ reported experience with pain from the Nursing Home Compare website and the Five Star Rating System.

    • We are also advising providers we will be updating the thresholds for quality measure ratings, according to the plan introduced in CMS Memorandum QSO-19-08-NH, in which the thresholds will be updated every six months. The first update will take place April 2020.

    • We are listing the dates the Nursing Home Compare website and the Five Star Rating System will be updated over the next few months.


    Consumer Alerts added to the Nursing Home Compare website and the Five Star Quality Rating System

    Memo #QSO-20-01-NH

    Posting Date 2019-10-07

    Fiscal Year 2020


    • Abuse Indicator –CMS is updating the Nursing Home Compare website to make it easier for consumers to identify facilities with instances of non-compliance related to abuse.

    • Consumer Alert for Oregon Nursing Homes – CMS will be adding a consumer alert on the Nursing Home Compare website for all Oregon facilities indicating that incidents of abuse may not be reflected on the Nursing Home Compare website. This action is in response to a recommendation by the Government Accountability Office (GAO).

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