As we begin a new year, many of us are reflecting back on 2022 to help us set goals for positive change in 2023. Do your goals include prioritizing 5-Star Improvement or better survey outcomes? As you know, both annual surveys and complaint surveys can have a significant impact on the overall 5-Star Rating. To help guide action planning, let’s review stats for the top survey trends of 2022—including where we stand on overdue annual surveys and deficiency trends,  and discuss tips for preparing for your 2023 survey.

Overdue Recertification Surveys

As of 12/11/22, 34.5% of the nation’s nursing homes have not had an annual survey in the past 15 months. In the following states, over 50% of the facilities in the state have not had an annual survey in over 15 months:

      • Maryland (88%)
      • Kentucky (84%)
      • Idaho (81%)
      • District of Columbia (76%)
      • Alabama (67%)
      • New Jersey (63%)
      • Missouri (59%)
      • Mississippi (56%)
      • California (55%)

16.9% of the nation’s nursing homes have not had an annual survey in over 24 months. Maryland, Idaho, and Kentucky have the most facilities that have not been surveyed in over 24 months (76% of Maryland facilities, 75% of Idaho facilities, and 73% of Kentucky facilities have not been surveyed in over 24 months).

Average Number of Deficiencies

In 2022,  an average of 6.9 deficiencies were cited on annual surveys nationally. The survey regions with the highest average number of citations on annuals are Region IX San Francisco (10.7) and Region X Seattle (11.0). The states with the highest average number of citations on annuals are: Washington (14.1), New Mexico (13.2), Maryland (13.1), West Virginia (13.0), District of Columbia (13.0), Nevada (12.3), California (11.8), Massachusetts (11.2), Missouri (10.6), Michigan (10.4), and Utah (10.2).

Top 5 Citations for Calendar Year 2022

      1. F884 NHSN Reporting – 30.5% of providers cited
      2. F880 Infection Prevention & Control – 25.8% of providers cited
      3. F689 Free of Accident Hazards/Supervision/Devices – 22.5% of providers cited
      4. F812 Food Procurement, Store/Prepare/Serve Sanitary – 21.6% of providers cited
      5. F684 Quality of Care – 18.1% of providers cited

 Achieving Survey Success in the New Year: Start Here

  1. The LTC Survey Pathways are an excellent resource to use for training and on-going monitoring for compliance in these areas. The Infection Prevention, Control, & Immunizations Pathway (CMS-20054), Dining Observation (CMS-20053), and Kitchen Observation (CMS-20055) are pathways that surveyors will use during every annual survey to assess your compliance with F880 Infection Prevention & Control and F812 Food Procurement, Store/Prepare/Serve Sanitary requirements. The Accidents Critical Element Pathway (CMS-20127) is a pathway that is triggered for use to further investigate if there are concerns identified in the care areas of accident hazards, falls, resident to resident interactions, smoking, or unsafe wandering/elopement to assess compliance with F689 Free of Accident Hazard/Supervision/Devices.

Facilities should establish processes to use the LTC Survey Pathways tools routinely to monitor compliance with these top cited F-Tags. If concerns are identified through the routine monitoring, the concerns should be reviewed with the QAPI committee and performance improvements plans implemented to address the identified concerns.

  1. A mock survey is also an invaluable process that should be used by all SNFs. A mock survey is an opportunity for you to take a fresh look at systems, procedures and processes of care to identify potential risk areas, so that you can address these risk areas through your performance improvement processes. It is also a wonderful process to “test” how your staff will perform and handle the stress associated with surveys and how your residents will respond to interviews conducted by surveyors.

One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. Proactive Medical Review & Consulting offers mock survey services to assist providers in preparing for the annual survey process by identifying potential areas that may be at risk related to your systems, procedures and processes of care, as well as consultations on developing a plan of correction, follow-up compliance visits, staff training, and on-going regulatory compliance consultation services.   50% of Proactive 2021 mock survey clients achieved a deficiency free survey in the annual health inspection following the mock survey.

  1. Proactive is offering a Deep Dive into Federal Regulations in a Year webinar series in 2023. This series is designed for those new to the long-term care industry or for those who would like a more comprehensive understanding of the federal regulatory requirements. Over the course of 12 monthly sessions, this series will provide a deep dive into learning about the federal regulations for long term care facilities. Resident rights, abuse/neglect/exploitation, admission/transfer/discharge, Resident assessment, comprehensive resident centered care plan, quality of life, quality of care, physician services, nursing services, behavioral health, pharmacy services, lab/radiology/diagnostic services, dental services, food/nutrition services, specialized rehab services, administration, QAPI, Infection Control, Compliance and ethics program, physical environment, and training requirements regulations and Interpretive guidance will be covered. Please plan to join us for this series to help your team understand the federal regulatory requirements to help prepare you for a successful 2023 survey. More information on this upcoming series and the full line up of Proactive training for 2023 can be found at Deep Dive into Federal Regulations: Full Series Purchase – Proactive Medical Review

Proactive LTC Consulting specializes in assisting facilities with Five-Star Rating Improvement plans and preparing providers for the LTC Survey Process. Contact us today for more information regarding our proven Five-Star Improvement partnerships and survey preparedness projects.

 Source: retrieved 12/16/22


Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
Director of Regulatory Services

Learn more about the rest of the Proactive team.