New Long Term Care Survey Process

In continuation of the regulation reform, on May 23, 2017 the Center for Medicare & Medicaid services (CMS) posted on the Nursing Home survey & certification website a slide presentation that provides details to the changes in the survey process that is planned for implementation on November 28, 2017. The change to the survey process is one of four initiatives scheduled for November of this year. The other initiatives include:

  • Implementation of Phase 2 requirements of participation
  • Updated Interpretive Guidelines
  • New F Tags

While New York has been utilizing the Quality Indicator Survey (QIS) process, a number of states have continued with the traditional survey process. CMS identified opportunities to improve the efficiency and effectiveness of both survey processes and recognized that slightly different quality of care and quality of life issues were identified, depending on the methods used by a surveyor. The goal is to establish a resident-centered, single nationwide survey process. The revised process builds on the best of both the traditional and QIS survey tasks and provides a balance between structure and surveyor autonomy.

Highlights of the new survey process noted by CMS include:

  • Survey is computer based with each surveyor using a tablet or laptop PC to record findings.
  • Information required upon entrance to the facility by Surveyors will include a completed Roster Sample Matrix Form (CMS-802) for new admissions over the last 30 days, facility census number, alphabetical listing of all residents and a list of residents who smoke with the facility’s designated smoking times, if applicable.
  • Upon entry to the facility, there will be no formal tour process. Surveyors will be assigned to units and will screen all residents to identify who should be included in the initial pool. Residents selected for the initial pool will include new admissions within the last 30 days, vulnerable residents who are dependent on staff and any active complaints or self- reported incidents.

It is anticipated that the surveyor will select about eight residents for the initial pool and will complete a full observation, interview, and a limited record review. A dining observation will be completed for the first full meal covering all dining rooms and room trays. Additional dining observations may be conducted based on identification of any concerns.

  • Resident interviews will be conducted for all interviewable residents in the initial pool. There will not be a specific script for the interview, but suggested questions will be provided to the surveyors. Interviews will be held with Resident representatives or families for Residents who are non-interviewable. At least three will be completed during the initial pool process or early enough to follow up on concerns. The goal will be to identify any concerns that warrant inclusion in the investigative portion of the survey process.
  • Surveyors will meet after the initial reviews are completed and discuss their findings. A second sample will be selected based upon the MDS indicators generated by the computer system and any concerns identified from the activities conducted with the initial pool. Residents who were selected based on MDS data who have been discharged will be replaced by residents identified onsite. Sample size is determined by the facility’s census with 70% pre-selected residents using MDS data and 30% surveyor selected residents. The sample size is approximately 20% of the facility total census with a maximum sample of 35 residents. Once the sample has been selected, surveyors will initiate an investigation focused on the specific areas identified for each of the residents in the sample using the critical element (CE) pathways.
  • Mandatory facility tasks during the survey process will include dining observations, infection control, SNF Beneficiary Notification Review, kitchen review, medication administration and storage, sufficient and competent nurse staffing, and QAA/QAPI. Each of these tasks will be assigned to a surveyor to complete.
  • There will continue to be a group interview with the active members of the Resident Council. In addition, minutes of previous resident council meetings will be reviewed to identify concerns.
  • There will be five residents selected by the computer system for a full medication review to determine compliance with the unnecessary medication requirements. . These residents may or may not be in the sample selection created by the team onsite after the initial pool reviews are completed. Residents selected for the full medication review will include those receiving insulin, an anticoagulant and an antipsychotic with a diagnosis of Alzheimer’s disease or dementia if available.
  • Closed record reviews will be selected either by the computer system or a recently discharged resident who is identified during the onsite survey. Focus will be on unexpected deaths, hospitalization, or community discharge within the last 90 days.
  • Medication administration observations will include 25 medication opportunities that reflect different units, shifts and routes of administration. Observations will include the sample residents if possible. In addition, at least half of the medication storage rooms and carts will be inspected for appropriate storage and labeling.
  • While surveyors will investigate any specific concerns identified with the environment, the goal is to eliminate redundancy with any tasks that are conducted during the Life Safety Survey.
  • Survey team will make the determination of compliance including scope and severity rather than just the computer software

Training on the new process will start in July 2017 for the CMS Regional offices and surveyors. New York State surveyors will be trained via computer based live remote interactive program on August 14th thru 18th. Provider training will be available thru national calls and access to the surveyor training materials which is projected for the late summer/fall of 2017.

Preparing for the new survey process

Understanding the survey process and managing a facility’s response to the survey team is critical to achieving a positive survey outcome. Preparing for the new process while gaining an understanding of the new interruptive guidelines and implementing the phase 2 requirements is a monumental task. However there are steps that can be taken to start preparing facility staff for the new process especially if you anticipate your annual survey in December or later:

  1. Educate your leadership team on the new survey process and develop a survey management process to meet the changes.
  2. Assist your staff in developing strategies for interacting with the surveyors when they are completing the initial pool reviews. This task is focused on observing all of the residents within the surveyor’s assigned units and positive interaction with staff will be key.
  3. Identify residents who may be at risk for selection in the initial pool or the resident sample. Utilizing your resident level quality measure reports and MDS data to identify residents who would meet the criteria for the new process including those who are vulnerable and dependent on staff, are receiving high risk medications including insulin, anticoagulants, and antipsychotic medications with a diagnosis of Alzheimer’s or dementia. Identify residents who trigger quality measures that are reflective of specific care areas such as weight loss, pressure ulcers, and falls.
  4. Conduct record reviews of residents at risk to identify any potential compliance concerns and identify opportunities for improvement in care processes or documentation.
  5. Conduct routine resident interviews as part of the Facility’s QAPI Program to identify resident’s concerns and ideas for improving care. Routine interviews by staff will prepare the residents if included in the surveyor’s interview process.

Loeb & Troper will be providing education for clinical staff to prepare for these challenges. If you have any questions or want to receive information concerning our educational opportunities, please contact Joanne Jones, RN, Director Clinical Consulting at or 212.697.3000