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!

  • Casper QM Reports / Data Specs Will Remain Out of Sync for Now

    By Caralyn Davis, Staff Writer - February 19, 2019

    On Feb. 1, the QIES Technical Support Office (QTSO) announced changes to the MDS 3.0 Quality Measure Reports in the CASPER Reporting application, including calculation updates/changes to the short-stay pressure ulcer measure, the long-stay pressure ulcer measure, and the long-stay weight loss measure. As a result, providers have been expecting the Centers for Medicare & Medicaid Services (CMS) to quickly release version 12 of the MDS 3.0 Quality Measures (QM) User’s Manual.


    However, CMS doesn’t share that sense of urgency, planning to release version 12 “in the next couple of months,” said officials during the Feb. 14 Skilled Nursing Facility/Long-term Care Open Door Forum (ODF). The methodology for those updated QMs “is not used in the public domain yet,” they explained to justify the agency’s delay in releasing new technical specifications.


    In other manual news, providers also won’t get the draft version of the next update to the RAI User’s Manual for the MDS 3.0 quite as early as most hoped to help them prepare for the Oct. 1, 2019, implementation of the Patient-Driven Payment Model (PDPM) under the Skilled Nursing Facility Prospective Payment System (SNF PPS).


    “We historically publish that manual more toward August,” said officials. “We do understand the need to be able to review [it for] the PDPM, so our goal is to have that published in May sometime this year.”

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  • SNF QRP 3Q 2018 Help Desk Q+A Doc Includes 2 GG Coding Q&As (2/19)

    By CMS - February 19, 2019
    A new Question and Answer (Q+A) document is now available from the SNF Quality Reporting Program FAQs webpage. The Q+A document reflects frequently asked questions that were received by the SNF QRP Help Desk during the third quarter (July - September) of 2018. It includes information about the SNF QRP program, as well as two section GG coding questions (related to GG0170N and GG0170O).
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  • New CMPRP Toolkit From CMS: Nursing Home Employee Satisfaction Survey (2/19)

    By CMS - February 19, 2019

    The employee satisfaction survey can help your nursing home to recruit, motivate and retain staff. After all, nursing home employees are critical to better resident health and quality of life.

    This free, anonymous survey offers facility employees an opportunity to share their perceptions about the nursing home workplace. Survey topics include:

    • Employee engagement and team building
    • Job satisfaction
    • Management and leadership
    • Scheduling and staffing
    • Training
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  • PDPM FAQs and Fact Sheets_Revised (2/19)

    By CMS - February 15, 2019

    Fact Sheets

    This section includes fact sheets on a variety of PDPM related topics.

    • Administrative Level of Care Presumption under the PDPM
    • PDPM Payments for SNF Patients with HIV/AIDS
    • Concurrent and Group Therapy Limit
    • PDPM Functional and Cognitive Scoring
    • Interrupted Stay Policy
    • MDS Changes
    • NTA Comorbidity Score
    • PDPM Patient Classification
    • Variable Per Diem Adjustment

    PDPM Frequently Asked Questions

    This section contains frequently asked questions (FAQs) related to PDPM policy and implementation.

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  • PDPM Training and Technical Resources, Including Grouper Logic & ICD-10 Crosswalks (2/19)

    By CMS - February 15, 2019

    PDPM Training Presentation

    This section includes a training presentation which can be used to educate providers and other stakeholders on PDPM policy and implementation.

    PDPM Resources

    This section includes additional resources relevant to PDPM implementation, including various coding crosswalks and classification logic.

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  • CMS Transmittal and MLN Connects Article on PDPM Implementation (2/19)

    By CMS - February 14, 2019

    CR 11152 effectuates changes to the SNF Prospective Payment System (PPS) that are required for the PDPM. These changes were finalized in the FY 2019 SNF PPS Final Rule (83 FR 39162). SNFs billing on Type of Bill (TOB) 21X and hospital swing bed providers billing on TOB 18X, (subject to SNF PPS) will be subject to these requirements. Make sure your billing staff is aware of these changes.

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  • AHRQ Surveys on Patient Safety Culture Nursing Home Survey: 2019 Database Report (2/19)

    By AHRQ - February 14, 2019

    The most recent AHRQ Nursing Home Survey on Patient Safety Culture Database Report presents data from 191 nursing homes and 10,499 nursing home respondents who completed the survey between January 2016 and July 2018 and submitted data to the Nursing Home SOPS database. The report presents statistics (averages, standard deviations, minimum and maximum scores, and percentiles) on the patient safety culture composite measures and items from the survey. Appendixes A and B present overall results by nursing home characteristics (bed size, ownership, census region, and urban/rural status) and respondent characteristics (job title, nursing home work area, interaction with residents, shift worked most often, and tenure in nursing home). The report contains data voluntarily submitted by participating nursing homes and is not representative of all U.S. nursing homes.

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  • All Cause Harm Prevention Webinar Recording Available (2/19)

    By NNHQIC - February 14, 2019

    All Cause Harm Prevention in Nursing Homes Applying Strategies from the New CMS Change Package

    Thursday, January 24, 2019, 3:00pm ET (1 hour) Recording Available.

    One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences.

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  • National Fire Protection Association (NFPA) 99 Health Care Facilities Code Training (NFPA99) (2/19)

    By CMS - February 14, 2019
    The NFPA 99 online training will be a self-paced, on-demand, asynchronous Federal training for all surveyors who have completed the necessary prerequisites. It will be housed on the ISTW. The NFPA 99 training is intended to cultivate and refine surveyor skills, foster understanding of the NFPA 99 requirements, and enhance surveyors’ overall ability to survey health care services or systems based on risk to the patients, staff, or visitors to minimize the hazards of fire, explosion, and electricity in health care facilities. The overall goal of this NFPA 99 Health Care Facilities Code training is for the learner to effectively survey for NFPA 99 compliance.
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  • Nurse Leader Reference Sheet

    By AADNS - February 12, 2019
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  • 7 Ways the DNS Can Lead the Charge for PDPM

    By Caralyn Davis, Staff Writer - February 12, 2019

    Many directors of nursing services (DNSs) have a hands-off approach when it comes to fee-for-service Medicare Part A and the MDS process, says Suzy Harvey, RN-BC, RAC-CT, managing consultant at BKD in Springfield, MO. “DNSs attend morning meetings and sometimes attend Medicare meetings, but they don’t really get involved because they count on their MDS staff to handle those processes.”


    That approach works for the RUG-IV case-mix classification system, but when the Skilled Nursing Facility Prospective Payment System (SNF PPS) switches to the Patient-Driven Payment Model (PDPM) on Oct. 1, rehabilitation therapy will no longer drive Part A skilled care, says Harvey. “With PDPM focused on patient characteristics and skilled nursing services instead of therapy volume, nursing will become key to facility success in this new system, and as the supervisor of the nursing staff, the DNS will need to help lead the way.”


    It’s important to note that working on PDPM isn’t just another task to add to the DNS’s plate, adds Harvey. “Getting paid appropriately is the focus of PDPM, but it ties back into quality of care. Much of what you will need to work on for PDPM will also benefit you on survey and your quality measures as well.”


    Here are seven key steps a DNS can take to get out in front of PDPM:

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  • F-Tag 760: Avoiding a Citation When Crushing Medication

    By Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT - February 12, 2019
    Some residents require or request that their medication be crushed for oral administration. But not following CMS guidelines for crushing medications could result in a citation under §483.45(f)(2) F760 (Residents Are Free of Any Significant Medication Error). This citation could also occur in administering crushed medications via feeding tube. Facility leaders and the nurse administering the medications must first be sure that the particular medication can be crushed per manufacturer instructions. The Institute for Safe Medication Practices website can be a helpful resource in determining which medications should not be crushed.
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  • Q&A: What is the best way to ensure that Notices of Transfer and Discharge are delivered appropriately?

    By AADNS Network - February 12, 2019
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  • OIG State Survey Agencies not Adequately Verifying Correction of Deficiencies (2/19)

    By OIG - February 08, 2019

    CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs To Be Improved To Help Ensure the Health and Safety of Nursing Home Residents (A-09-18-02000)

    State survey agencies (State agencies) must verify that nursing homes corrected identified deficiencies, such as the failure to provide necessary care and services, before certifying whether the nursing homes are in substantial compliance with Federal participation requirements for Medicare and Medicaid.

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  • DRAFT MDS Data Specs and CAT Specs for Oct. 1, 2019

    By CMS - February 05, 2019

    A new version (V3.00.0) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2019.  Note that there are many significant changes, including the removal of eight item sets (NS, NSD, NO, NOD, SS, SSD, SO, SOD), the addition of two new item sets (IPA and OSA), and item additions in Sections A, GG, I, J, O and Z. These specs accommodate the utilization of the PDPM grouper, which also begins on October 1, 2019.

    In addition, a new version (V1.04.0) of the MDS 3.0 CAT Specifications was posted. This version is also scheduled to become effective October 1, 2019. The specification for CAT 12 (Nutritional Status) has been updated in accordance with the changes in V3.00.0 of the MDS 3.0 Data Specifications.

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