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!

  • Why Some Bad Results Haunt NHC QMs/Five Star—and What to Do

    By Caralyn Davis - November 05, 2018

    The MDS-based CASPER Quality Measures (QMs) that are posted on Nursing Home Compare, some of which drive the QM domain in the Five-Star Quality Rating System, are a frequent source of headaches for directors of nursing services (DNSs). “Everyone wants Five-Stars in the overall composite rating to attract clients, but adverse events often linger on the CASPER QMs much longer than many DNSs and administrators think they will,” says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA.


    DNSs should have a basic idea of how long adverse events will impact the CASPER QMs, but that shouldn’t be the primary concern, suggests Maher. “The QMs will impact the overall Five-Star rating, but they have a lesser impact than the survey/health inspection and staffing domains. You must have Five-Stars in your QM domain to be able to add a star to your overall rating, and even Five-Stars in the QMs won’t help if your health inspection rating is one star and you’ve already added a star via the staffing domain. In addition, you have to have only one star in the QM domain to negatively affect your overall rating.” Note: For more information, see the “Overall Nursing Home Rating (Composite Measure)” section of the Nursing Home Compare Five-Star Quality Rating System Technical Users’ Guide.


    So the CASPER QMs are most important as a tool that DNSs can use to identify opportunities for improvement, stresses Maher. “If you focus on providing person-centered care and improving care, you will get to five stars.”

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  • Boost Staff Retention with Appreciation

    By AADNS - November 05, 2018

    In a recent McKnight’s article about Fortune magazine’s “Best Workplaces for Aging Services” and how skilled nursing reached the top of the list, the president and CEO of Van Dyk Healthcare of Hawthorne, NJ, Robert Van Dyk, is quoted with a message about how you have to make sure you care for those who work so hard taking care of your residents if you want to be a best workplace. How do you take care them? Show them appreciation – all the time.

    Aspiring to create a great place for employees to work should always be on the minds of leadership personnel. However, if you are struggling with staff retention, it might be time to take a good look at your culture and how you are appreciating your team.

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  • Q&A: Would anyone be willing to share their bed-hold policy?

    By Jeanne Gerstenkorn DNS-CT,BSN,MSN,RN,QCP,RAC-CT - November 05, 2018
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  • SNF QRP Provider Preview Reports for Nursing Home Compare Available (11/18)

    By CMS - November 01, 2018
    Skilled Nursing Facility Provider Preview Reports have been updated and are now available. Providers have until November 30, 2018 to review their performance data on quality measures based on Quarter 2 -2017 to Quarter 1 - 2018 data, prior to the January 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate
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  • National Palliative Care Clinical Practice Guidelines Updated (11/18)

    By National Consensus Project for Quality Palliative Care - November 01, 2018

    New national palliative care clinical practice guidelines seek to ensure the millions of people living with serious illness, such as heart failure, lung disease and cancer, have access to vital care that can help meet their needs. The guidelines promote improved access to palliative care, which is focused on giving patients and their caregivers relief from the symptoms and stress of serious illness, is based on need, not prognosis, and can be provided along with disease-focused treatment.

    The Clinical Practice Guidelines for Quality Palliative Care, 4th edition calls for a seismic shift in the delivery of this specialized care by urging all health care professionals and organizations to integrate it into the services they provide to people living with serious illness. The guidelines also include tools, resources and practice examples to help with implementation. 

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  • Wound Management Best Practice Intervention Package (11/18)

    By National Nursing Home Quality Improvement Campaign (11/18) - November 01, 2018

    Note: The package is home health-focused and may need tweaking for long-term care.


    This package brings together evidence-based practices and tools from leading expert organizations, such as Wound, Ostomy, and Continence Nurses Society (WOCN); National Pressure Ulcer Advisory Panel (NPUAP); International Skin Tear Advisory Panel (ISTAP); and Centers for Medicare & Medicaid Services (CMS).

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  • Toolkit for CDI Prevention and Management in Long Term Care (11/18)

    By National Nursing Home Quality Improvement Campaign - November 01, 2018

    New toolkit alert from the National Nursing Home Quality Improvement Campaign:


    The Minnesota Department of Health's toolkit for C. diff infection (CDI) prevention and management in long-term care includes resources in six topic areas: prepare, detect, contain, clean, prevent, and educate.

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  • SNF VBP: Updated FY 2019 Rankings (11/18)

    By CMS - November 01, 2018

    The Centers for Medicare & Medicaid Services (CMS) thanks all skilled nursing facilities (SNFs) that participated in Phase Two of the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program’s Review and Corrections process. As a result, CMS is providing updated rankings for all SNFs included in the Fiscal Year (FY) 2019 program year. A list of each SNF’s incentive payment multiplier and updated ranking can be found on the SNF VBP website

    The incentive payment multiplier applicable to each SNF is unchanged from the multiplier that CMS previously included in the SNF’s FY 2019 Annual Performance Score Report. That multiplier will be used to adjust the Federal per diem rate otherwise applicable to the SNF for services furnished from October 1, 2018 through September 30, 2019. A more detailed file containing facility level performance will be made publicly available later this year on Nursing Home Compare.

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  • SNF QRP Annual Payment Update Warning Edits (11/18)

    By CMS - November 01, 2018

    To assist SNFs, CMS is excited to announce new Skilled Nursing Facility (SNF) Annual Payment Update (APU) warning edits are being incorporated into the MDS technical submission specifications.  These warning edits appear as both pop-up messages in jRAVEN, the free CMS software that allows SNFs to submit MDS data to CMS in the proper format, and also on the MDS 3.0 Final Validation Report (FVR). The edits will appear when required standardized patient assessment data elements and data elements required for quality measure calculation for the purposes of the SNF QRP are dashed. These warning edit will display on FVR as error identification numbers:-3897, -3907 or -3908. Warning edits do not prevent MDS 3.0 assessment from being accepted by the Assessment Submission and Processing (ASAP) system.

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  • F684: Handling this Broad Tag Requires Analysis and Action

    By Caralyn Davis, Staff Writer - October 25, 2018

    Surveyors in the long-term care survey process (LTCSP) have begun to cite F684 (Quality of Care) with increasing frequency. As of July 2018, F684 is fifth most-common LTCSP tag. In comparison, it was the eighth most common in February, according to the July data available in QCOR, the Quality, Certification, and Oversight Reports site of the Centers for Medicare & Medicaid Services (CMS).

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  • CMS Will Conduct Focused Dementia Care and Focused Schizophrenia Surveys in FY 2019

    By CMS - October 25, 2018
    Focused Dementia Care Surveys: FY2019, CMS plans to have federal contract surveyors conduct additional focused dementia care surveys in some states. Due to concerns about facilities using an inappropriate process to diagnose residents with schizophrenia, we also expect to conduct a limited number of surveys focused on this issue.
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  • Influenza: How to Prevent or Minimize Outbreaks

    By Caralyn Davis, Staff Writer - October 25, 2018

    Through Oct. 13, influenza activity remained low across the United States. However, the Centers for Disease Control and Prevention (CDC) expects flu outbreaks to increase in the coming months. Avoiding and minimizing flu outbreaks not only protects residents and staff, it protects the facility as well given the laser focus on infection prevention and control that state surveyors have had during the first year of the Long-term Care Survey Process (LTCSP).

    Directors of nursing services (DNSs) can work with the interdisciplinary team, residents, and families to reduce the risk of influenza transmission and minimize any outbreaks that occur. Limiting transmission requires a bundled approach, including the following steps:

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  • Study: Treating Delirium With Antipsychotic Meds May Not Be Best Option (10/18)

    By National Institute on Aging - October 25, 2018

    NIH-funded clinical trial suggests reconsidering current strategies to treat delirium.

    Critically ill patients in intensive care units (ICUs) did not benefit from two antipsychotic drugs used to treat delirium, according to a large clinical trial funded by the National Institute on Aging, part of the National Institutes of Health. The multi-site team that conducted the trial found no evidence that treatment with antipsychotic medicines — haloperidol or ziprasidone — affected delirium, survival, length of ICU or hospital stay or safety. The findings from the Modifying the Incidence of Delirium USA (MIND USA) study were published online Oct. 22, 2018 in The New England Journal of Medicine.

    “This is strong evidence from what we consider a ‘gold standard’ clinical trial showing that these two antipsychotics don’t work to treat delirium during a critical illness,” said NIA Deputy Director Marie A. Bernard, M.D. “Antipsychotics have often been used to treat delirium. The evidence from this study suggests the need to reexamine that practice.” Bernard is also NIA’s senior geriatrician.

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  • SNF QRP Public Reporting on Nursing Home Compare: 5 QMs (10/18)

    By CMS - October 24, 2018

    On Oct. 24, 2018, in accordance with Section 1899B(g)(1) of the Social Security Act, which requires CMS to provide for the public reporting of SNF provider performance on the quality measures, CMS announced the inaugural release of the Skilled Nursing Facility  Quality Reporting Program (SNF QRP) quality data on Nursing Home (NH) Compare.

    Specifically, the following five SNF QRP measures are now being displayed on the NH Compare site:

    Assessment-based measures:

    1. Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (National Quality Forum #0678)
    2. Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
    3. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)

    Claims-based measures:

    1. Medicare Spending Per Beneficiary-PAC SNF QRP
    2. Discharge to Community-PAC SNF QRP

    CMS has decided not to publish a 6th quality measure, Potentially Preventable 30-Day Post-Discharge Readmissions, at this time.   Additional time would allow for more testing to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure. This additional testing will ensure that the future publicly reported measure is thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality.   While we conduct this additional testing, CMS will not post reportable data for this measure, including each SNF’s performance, as well as the national rate.


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  • Free AHRQ Antibiotic Stewardship Training: Is It Right for Your Facility?

    By AHRQ - October 24, 2018

    While F881 (antibiotic stewardship program) citations remain low overall compared to other citations nationwide, as of Oct. 15, 2018, QCOR data, F881 is now the 10th most-cited new F-tag with a severity level of F or above. -Staff

    Register now to attend a one-hour webinar that explains how long-term care facilities can run an effective antibiotic stewardship program by joining a free, 12-month national project. Beginning in December, the AHRQ Safety Program for Improving Antibiotic Use will provide participating long-term care facilities with antibiotic use guidelines, expert coaching, online education, improvement tools and patient education materials to help prevent harms associated with antibiotics, such as Clostridium difficile. Participants also have the opportunity to earn continuing education credits. 

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