Published October 4, 2018

Since November 28, 2017, everyone has had a little less survey stress knowing their survey outcomes would not impact their Five Star Rating. Unfortunately, those days are dwindling and it’s time to put this topic back on the table. Details of the survey freeze can be found on S&C memorandum 10-04-NH.

CMS has not yet announced the methodology they will use to resume health inspection rating calculations but we do know they have been monitoring outcomes of the new inspection process and plan to resume health inspection rating calculations (i.e., end the freeze) in the Spring of 2019.  In addition, CMS indicated that the average number of citations per inspection for each state and nationally will resume in October 2019.

With those time frames in mind, it’s time to put your survey readiness hats on and ensure your facility is prepared. Remember, survey outcomes hold the most impact on your overall Five Star Rating!

Getting your plan together is the first step. Consider these approaches:

1. CASPER Quality Measure Report (Resident Level Report); identify residents that trigger for a high number of measures, or for measures that have high level impact, and assign thorough medical record reviews.
2. Past Survey Results; recognize that areas for past deficiencies (past 3 years) are focus areas under your current survey. Conduct random audits to ensure continued compliance and that processes are being followed.
3. Conduct a Survey Preparedness Review; focus on the 9 mandatory Critical Element Pathways (CEPs), ABN, Dining, Infection Prevention Control & Immunization, Kitchen, Med Administration, Resident Council, QAA and QAPI, Sufficient & Competent Staff, Medication Storage.

Good performance in these areas can help avoid expansive inclusion of the other CEPs. Assigning the mandatory CEPs to your team, with the expectation that their findings be brought back to the QAA Committee, will promote team involvement and integration of noted opportunities into your QAPI Program. Keep in mind, under F865, “… the facility must provide satisfactory evidence that it has, through its QAA committee, identified its own high risk, high volume, and problem-prone quality deficiencies, and are making a “good faith attempt” to correct them.”

4. Survey Readiness Binder; consider having all required items on the Entrance Conference Worksheet organized in a binder. This will make a good first impression with the survey team and allow you and your team to be out rounding on the resident units to ensure processes are in place and staff are supported.

Last, set improvement priorities! Priorities can be established if the identified opportunity aligns with a recent survey deficiency (past 3 surveys) and/or it falls into one of your top 10 state deficiencies.

We recognize these challenging times so please don’t hesitate to reach out to us for assistance or if you have any questions.

Amy Lee, RN, MSN, CRRN, QCP
President/CEO