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!

  • OIG Audit Finds Staff Didn't Always Comply With Care Plan for Residents With UTI at One NF (6/19)

    By OIG - June 19, 2019

    Princeton Place Did Not Always Comply With Care Plans for Residents Who Were Diagnosed With Urinary Tract Infections (A-06-17-02002)

    Princeton Place did not always provide services to Medicaid-eligible residents diagnosed with UTIs in accordance with their care plans, as required by Federal regulations. Specifically, Princeton Place staff did not always document that they monitored the residents' urine appearance at the frequencies specified in their care plans. Princeton Place did not have policies and procedures to ensure that its staff provided services in accordance with its residents' care plans. As a result of Princeton Place not following residents' care plans, the residents were at increased risk for contracting UTIs and for incurring complications from UTIs, including requiring hospitalization.

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  • CDC Infection Control Interactive Graphic Novel for Environmental Services (EVS) Personnel (6/19)

    By CDC - June 19, 2019

    EVS personnel play a critical role in preventing the spread of germs and healthcare-associated infections

    EVS and the Battle Against Infection” is an interactive graphic novel illustrating the important role of EVS personnel in the prevention of healthcare-associated infections. The online version of the training tool features real-world infection prevention and control scenarios and allows participants to choose options that affect the outcome of the story. 

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  • CDC Interactive Training: Reducing HAI Transmission Risk (6/19)

    By CDC - June 19, 2019

    Healthcare professionals are the first line of defense against healthcare-associated infections (HAIs) and the spread of germs in healthcare settings. CDC now offers a new online interactive infection control training, “Let’s Talk Patient Safety: Reducing HAI Transmission Risk,” to help healthcare professionals identify infection risks and prevent the spread of HAIs. The training provides free continuing education for healthcare professionals, including nurses, physician assistants, medical assistants, health educators, and other clinicians. (0.1 CEU and 0.6 CNE).

    The free online training can be completed anywhere. It has two modules and takes approximately 30 minutes to complete the entire training.

    Module 1: “What’s the Risk?” 

    This interactive module transports healthcare professionals into a scenario where they must identify infection risks and take action to protect patients, colleagues, and visitors. 

    Module 2: “Chain of Infection” 

    This story-based interactive module challenges professionals to break the chain of infection in a busy healthcare environment and educates them on the consequences of not following infection prevention and control recommendations.

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  • Early Identification of Sepsis in Nursing Facilities: Opportunities and Hurdles Recorded Webinar/Slides (6/19)

    By NNHQIC - June 19, 2019

    Please join Christine LaRocca, MD and the National Nursing Home Quality Improvement Campaign to learn more about sepsis, who is at risk and the signs and symptoms for early detection. In addition, we will:

    ·        Review examples of sepsis screening tools commonly used in hospital settings;

    ·        Learn what tools to use while recognizing the limitations of sepsis screening tools in the nursing home population; and

    ·        Understand the elements of evidence-based treatment for optimal outcomes.

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  • July 11 NNHQIC Staff Stability Webinar: Register Now

    By NNHQIC - June 19, 2019

    National Nursing Home Quality Improvement Campaign Staff Stability Webinar

    Staff Stability allows a community to benefit from experience and knowledge that staff gain over time, increasing the overall competence and confidence of staff, while building strong bonds between residents and caregivers. Please join us to explore approaches to creating a culture of staff stability, including what tools to use for tracking progress, as well as additional resources the Campaign has made available to support you on this journey.

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  • Nursing Home Compare 2019 Anticipated Refreshes and Data Collection Timeframes for SNF QRP QMs (6/19)

    By CMS - June 16, 2019

    This table provides the data collection timeframes for quality measures in the Skilled Nursing Facility Quality Reporting Program (SNF QRP) displayed on the Nursing Home Compare website for Calendar Year (CY) 2019. The first column displays the plain language measure name used on the Compare website, the second column displays the full technical measure name, the third column displays the reporting cycle which describes the collection period and refresh frequency, and the last four columns contain the timeframe for each quarterly Compare website refresh.

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  • Skilled Nursing News Hosts First Annual Summit

    By AADNS - June 14, 2019

    AAPACN President and CEO, Tracey Moorhead, attended Skilled Nursing News’ (SNN’s) inaugural, half-day Summit in Chicago on June 6. The event attracted more than 250 skilled nursing leaders representing providers, investors, technology innovators, and business solutions. Read this blog for important highlights from the panel discussions!

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  • PACIO Project (Post-Acute Care Interoperability) Seeks Participants (6/19)

    By CMS - June 13, 2019
    The PACIO Project (Post-Acute Care Interoperability), pronounced "passeeo", launched on February 26, 2019. The goal of this collaborative partnership is to establish a framework for the development of a Fast Healthcare Interoperability Resource (FHIR) technical implementation guide(s) and Reference Implementations that will facilitate health information exchange through standards-based application programming interfaces (APIs). The objective of the PACIO Project is to use a consensus-based approach to advance interoperable health data exchange between post-acute care providers, patients, and other key stakeholders across the health care continuum with policy makers, standards organizations, and industry. This project is open to everyone, led by the MITRE Corporation, and participants include health IT vendors, providers, clinicians, researchers, standards organizations, CMS, ONC, and the VA.
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  • Abuse and Neglect of Medicare Beneficiaries: OIG Targets SNFs (6/19)

    By OIG - June 12, 2019

    The Department of Health and Human Services Office of Inspector General issued two new reports that address the identification, reporting and investigation of incidents of potential abuse and neglect of our nation's most vulnerable populations, including seniors and individuals with developmental disabilities. OIG issued an early alert in 2017 based on the preliminary findings of this work. Our resulting work, released in June 2019, identify thousands of Medicare claims that indicate abuse and neglect of beneficiaries, including beneficiaries in skilled nursing facilities. If you suspect someone is the victim of abuse or neglect, contact law enforcement immediately.


    CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect 

    Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated


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  • A Surprising F-Tag Has Joined the Top 10 Cited Deficiencies

    By Jane Belt, MS, RN, RAC-MT, RAC-MTA, QCP - June 12, 2019

    In the realm of the revised survey process, an interesting F-tag has joined the list of the most frequently cited deficiencies across the country. The tag is F-842, and in case that regulatory number is not immediately familiar, it has to do with documentation: “Resident Records – Identifiable Information.”


    Given our profession’s consistent focus on documentation, does that come as a surprise? It certainly did for this writer! Between January 2018 and April 2019, F-842 has been cited nearly 3,000 times, across all CMS Survey and Certification Regional Offices. In 2019 so far, there have been 250 deficiencies cited under F-842. Long-term care has long been required to maintain residents’ personal privacy and keep medical records confidential. This is not a new requirement of participation, so what is happening? Many of the citations stem from the medical record not being accurate and complete, which is a component of F-842.


    Below are brief descriptions of a few of the cited deficiencies.

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  • Trauma-Informed Care: What It Is—and Isn’t

    By Caralyn Davis, Staff Writer - June 12, 2019

    Effective this November 28, trauma-informed care will take center stage in the survey process for nursing facilities (NFs) and skilled nursing facilities (SNFs) as the Centers for Medicare & Medicaid Services (CMS) completes the final stage of rolling out the revised requirements for participation in Medicaid and Medicare. CMS will implement new trauma-informed care regulations under F699 (trauma-informed care), which is a quality-of-care F-tag; F659 (comprehensive care plans/qualified persons); F741 (sufficient/competent staff‐behavioral health needs); and F949 (behavioral health training).


    These new or revised F-tags will come on top of two already implemented tags that address trauma—F742 (treatment/service for mental/psychosocial concerns) and F743 (no pattern of behavioral difficulties unless unavoidable)—giving surveyors a full suite of trauma-informed care tags to guide their investigations. Note: Read the Code of Federal Regulations citations that underpin the trauma-informed care requirements for each F-tag at the end of this article.

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  • Q&A: I just found out my facility was placed on a focus list! Any advice?

    By Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA - June 12, 2019
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  • Infection Prevention and Control: June 20 CDC Webinar on Multidrug-resistant Candida auris

    By CDC - June 11, 2019

    Multidrug-resistant Candida auris:

    Update on Current U.S. Epidemiology, Clinical Profile, Management, and Control Strategies

    Candida auris (C. auris) is an emerging fungus that presents a serious global health threat. CDC is concerned about C. auris for 3 main reasons:

    1. It is often multidrug-resistant, meaning multiple antifungal drugs are less or not at all effective in treating C. auris.
    2. It is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management.
    3. It has caused outbreaks in healthcare settings. It is important to quickly identify C. auris in a hospitalized patient so that healthcare facilities can take special precautions to stop its spread.

    Most C. auris cases in the United States have been detected in the New York City area, New Jersey, and the Chicago area. Clusters of cases have also recently been described in Florida, Texas, and California. C. auris cases in the United States are originally a result of inadvertent introduction into the United States from a patient who had received healthcare in a country where C. auris has been reported. Most cases now are a result of local spread after such an introduction.

    During this COCA Call, CDC presenters will

    • Provide an update on the current status of C. auris
    • Explain why it is a public health threat
    • Review current U.S. epidemiology and resistance patterns to antifungal drugs
    • Discuss clinical considerations when treating patients for C. auris
    • Lay out steps for identifying and controlling C. auris.
    • Date: Thursday, June 20, 2019
    • Time: 2:00–3:00 p.m. (ET)
    • Free continuing education (CE) is available for this COCA Call.  

    Nursing home-specific guidance from the CDC

    Nursing homes

    Nursing homes should follow all of the same recommendations listed for general acute care hospitals and high acuity post-acute care settings. Additional considerations are as follows:

    • In general, nursing home residents should be placed on Standard and Contact Precautions.
    • Functional nursing home residents without wounds or indwelling medical devices (e.g., urinary and intravenous catheters and gastrostomy tubes) who can perform hand hygiene might be at lower risk of transmitting C. auris. Facilities could consider relaxing the requirement for Contact Precautions for these residents. However, in these instances, healthcare personnel should still use gowns and gloves when performing tasks that put them at higher risk of contaminating their hands or clothing. These tasks include changing wound dressings and linens and assisting with bathing, toileting, and dressing in the morning and evening.
    • Nursing home residents with C. auris can leave their rooms as long as secretions and bodily fluids can be contained and the patient can perform hand hygiene prior to leaving their room.
    • If residents with C. auris receive physical therapy or other shared services (e.g., physical therapy equipment, recreational resources), staff should not work with other patients while working with the affected patient. They should use a gown and gloves when they anticipate touching the patient or potentially contaminated equipment. Ideally, affected patients should be the last to receive therapy on a given day. Shared equipment should be thoroughly cleaned and disinfected after use.



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  • FY 2021 SNF QRP Table for Reporting Assessment-Based Measures (6/19)

    By CMS - June 11, 2019
    The SNF QRP Table for Reporting Assessment-Based Measures for the FY 2021 SNF QRP APU is now available for download on the Skilled Nursing Facility (SNF) Quality Reporting Program Measures and Technical Information webpage. This table indicates the MDS data elements that are used in determining the APU minimum submission threshold for the FY 2021 SNF QRP determination.
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  • CMS Section GG Training Videos: GG0110, GG0170C, GG0130B, Decision Tree for GG0130/GG0170 (6/19)

    By CMS - June 10, 2019

    These apply to all four QRP programs, including the SNF QRP:

    • GG0110 Prior Device Use with Information From Multiple Sources. This 4-minute video demonstrates how a caregiver can utilize information collected from multiple scenarios to accurately code GG0110. Prior Device Use. 
    • Decision Tree for Coding Section GG0130. Self-Care and GG0170. Mobility. This 12-minute video demonstrates how to apply the six-point coding scale to GG0130. Self-Care and GG0170. Mobility using GG0170D. Sit to stand as an example.
    • Coding GG0170C. Lying to sitting on side of bed This 4-minute video demonstrates how to distinguish between Code 02, Substantial/maximal assistance and Code 03, Partial/moderate assistance when coding GG0170C. Lying to sitting on side of bed.
    • Coding GG0130B. Oral HygieneThis 4-minute video demonstrates how to distinguish between Code 05, Set-up or clean-up assistance and Code 04, Supervision or touching assistance when coding GG0130B. Oral Hygiene. 
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