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 Survey, from Dementia and MDS focused surveys, to what’s happening in SNFs around the country with the following articles. 

  • A Small Deed is a Big Deed to the Residents in Long-Term Care

    By Julie Conboy Russo, MS, RN, QCP - August 23, 2017
    Julie Conboy Russo, MS, RN, QCP, an AADNS member, tells her long-term care story about how she works every day to make a difference in someone else’s life, no matter how small that difference may seem. Read about her vision for the future of LTC and decide for yourself if you are ready to join her and so many other nurse leaders who are working toward quality resident care.
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  • At A Glance QM, QRP, and VBP Tool

    By AADNS - August 22, 2017
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  • SNF QRP Review and Correct Reports: CMS IDs Two Problems (8/17)

    By CMS - August 21, 2017

    CMS has identified two issues with the SNF Review and Correct Report.

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  • CMS Proposes Scaling Back CJR, Canceling Other New Payment Models (8/17)

    By CMS - August 21, 2017
    On Aug. 15, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule to reduce the number of mandatory geographic areas participating in the Center for Medicare and Medicaid Innovation’s (Innovation Center) Comprehensive Care for Joint Replacement (CJR) model from 67 to 34. In addition, CMS proposes to allow CJR participants in the 33 remaining areas to participate on a voluntary basis. In this rule, CMS also proposes to make participation in the CJR model voluntary for all low volume and rural hospitals in all of the CJR geographic areas.
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  • F881: Keys to a Compliant Antibiotic Stewardship Program

    By Caralyn Davis, Staff Writer - August 21, 2017
    Effective Nov. 28, 2017, all Medicare- and Medicaid-certified nursing homes must have an antibiotic stewardship program that includes antibiotic-use protocols and a system to monitor antibiotic use as part of their infection prevention and control program (IPCP), according to §483.80 (Infection Control) of the Code of Federal Regulations. The antibiotic stewardship program is a component of the Phase 2 rollout of the Reform of Requirements for Long-term Care Facilities, and surveyors will assess compliance with this new requirement of participation under F-tag 881 during the Infection Control Facility Task that is a mandatory part of the new survey process. Note: The F881 interpretive guidance can be found in the advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual.
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  • Appendix PP Part 1: CMS Officials Highlight Key Interpretive Guidance

    By Caralyn Davis, Staff Writer - August 21, 2017
    Hundreds of pages of new or revised interpretive guidance for surveyors will go into effect on Nov. 28, 2017, in conjunction with the Phase 2 roll-out of the Reform of Requirements for Long-term Care Facilities and the implementation of the new survey process. The interpretive guidance can be found in the advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” of the State Operations Manual. Officials with the Centers for Medicare & Medicaid Services (CMS) took providers on a “greatest hits” tour of important changes to Appendix PP during the July 25 MLN National Provider Call on the Revised Interpretive Guidance for Nursing Homes and New Survey Process. (Access the call slides, as well as the transcription and recording when available, here.)
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  • Q&A: My nursing facility is using an outdated practice to check feeding tube placement. What should I do?

    By Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT - August 20, 2017
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  • Sept. 7 Facility Assessment Tool and State Operations Manual Revisions Call: Register Now

    By CMS - August 14, 2017
    During this call, learn about the new Facility Assessment Tool to help identify and develop the specific assessment of your facility. Also, find out about frequently asked questions related to revision of the State Operations Manual Appendix PP for Phase 2 of the Reform of Requirements for Long-Term Care Facilities final rule. A question and answer session follows the presentation.
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  • CMS S&C Memo: Survey Team Composition and Investigation of Complaints (8/17)

    By CMS - August 14, 2017

    Survey Team Composition and Investigation of Complaints: On July 31, 2017, the Federal Register issued the final rule Medicare Program: Prospective Payment - System and Consolidated Billing for Skilled Nursing Facilities (SNF) for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020. These regulations are effective on October 1, 2017.

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  • Cultivating Health Literacy to Improve Outcomes

    By Amy Stewart. RN, DNS-MT, QCP-MT, RAC-MT - August 14, 2017
    Health literacy has always been an essential component of successful transitions of care, particularly at the point of discharge to the community. Limited health literacy is associated with a greater number of hospitalizations, more frequent emergency room visits, and an increase in adverse health behaviors. 

    Older adults tend to be more at risk for adverse events because of challenges with health literacy, according to the Cumulative Index to Nursing and Allied Health Literature Nursing Guide.

    With the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) claims-based quality measure, Discharge to Community–Post Acute Care, which links successful discharge to payment, and the new publicly reported quality measure, Successful Discharge to the Community, ensuring residents’ health literacy is more important than ever for SNFs.

    Read more of AADNS curriculum development specialist Amy Stewart's article in Provider magazine.

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  • Life Safety Code: CMS S&C Memo (8/17)

    By CMS - August 14, 2017
    Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies
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  • Looking for a Daily Challenge? Become a Nurse Leader in Long-Term Care

    By Glenda Nelson, RN, BSN - August 09, 2017

    Read about AADNS member, Glenda Nelson, RN, BSN, and her career journey from acute care to long-term care. Her passion for challenging herself and encouraging others is an inspiration. If you’re considering a career in LTC, Glenda’s story is a must-read.

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  • Q1 2017 Antipsychotic Medication Use Data Report From CMS (8/17)

    By CMS - August 09, 2017
    National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report: CMS is tracking the progress of the National Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In 2011Q4, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 34.1 percent to a national prevalence of 15.7 percent in 2017Q1. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 35 percent.

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  • Read Appendix PP: Here’s a Survey Study Guide

    By Caralyn Davis, Staff Writer - August 09, 2017

    “Quite a bit” of the regulatory requirements for survey won’t change with the Nov. 28, 2017, rollout of Phase 2 of the Reform of Requirements for Long-term Care Facilities (aka Mega-Rule), say officials with the Division of Nursing Homes in the Survey and Certification Group at the Centers for Medicare & Medicaid Services (CMS) during the video Appendix PP: Overview of Revised Interpretive Guidance.

    “Most of the minimum quality standards that were in the regulation remain,” they explain. “There are still strong resident rights, use of the Minimum Data Set to do assessment and care planning based on the residents’ goals and preferences, and the input of the interdisciplinary team. There are still requirements for a medical director, a full-time licensed nurse, and requirements for medication review.”

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  • F602 – F605: CMS Breaks Out New Guidance Re: Exploitation, Restraints

    By Caralyn Davis, Staff Writer - August 09, 2017

    Ten F-tags will address §483.12 (Freedom From Abuse, Neglect, and Exploitation) in the Code of Federal Regulations for the new survey process that rolls out Nov. 28, 2017. Some tags include both regulatory changes and updated interpretive guidance for surveyors in the advance copy of Appendix PP, “Guidance to Surveyors for Long-term Care Facilities,” in the State Operations Manual. However, other tags don’t have regulatory changes but still have revised interpretive guidance at the request of surveyors, say officials with the Centers for Medicare & Medicaid Services (CMS) during the surveyor training video Freedom From Abuse, Neglect, and Exploitation.

    Here are highlights of key changes for the “right to be free” tags F602 – F605:

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