Is your facility survey ready? According to CASPER (9/17/23), nearly 12% of the nation’s LTC facilities have not had a recertification survey in over 24 months. The states with the highest percentages include:

      1. Kentucky – 76.3%
      2. Maryland – 73.3%
      3. Idaho – 67.9%
      4. Alabama – 55.1%
      5. Tennessee – 38.5%

Nursing homes typically use the results of surveys to identify areas of non-compliance and quality improvement opportunities. The significant delays in recertification surveys can have a notable impact on survey readiness, creating challenges for both nursing home administrators and staff. Delays in surveys mean that facilities may not receive timely feedback on potential deficient practices and this can hinder their ability to make necessary improvements and to  be in a constant state of readiness for surveys. This week’s blog discusses systems for internal compliance rounding to facilitate consistent compliance and maintenance of quality standards.

Systems for Survey Readiness – Compliance Rounding

Nursing homes are entrusted with providing quality care and maintaining compliance with regulations to ensure the well-being of their residents. A crucial system that facilitates this is Compliance Rounding.

Understanding Compliance Rounding

Compliance Rounding is a systematic and structured approach to evaluating and improving the quality of care within nursing homes. It entails regular, thorough assessments of various facets of care delivery to ensure alignment with both regulatory requirements and industry best practices. These assessments encompass areas such as resident care, documentation, staff training, facility safety, and infection control.

The Vital Role of Compliance Rounding

  1. Ensuring Regulatory Compliance: Compliance Rounding is pivotal in helping nursing homes maintain compliance with regulations set forth by agencies like the Centers for Medicare & Medicaid Services (CMS). By proactively identifying areas of non-compliance and addressing them, nursing homes can minimize the risk of citations, penalties, and harm to residents.
  2. Enhancing Resident Safety: Resident safety is paramount. Compliance Rounding aids in the regular assessment and improvement of safety protocols, infection control measures, and emergency preparedness. This ensures that residents are provided a secure and safe environment.
  3. Improving Documentation Practices: Meticulous documentation is a cornerstone of survey readiness. Compliance Rounding incorporates a review of documentation practices, helping staff maintain accurate and comprehensive records that are crucial during surveys and audits.
  4. Facilitating Staff Training: Education and training for staff members are essential components of providing quality care. Compliance Rounding identifies training needs and ensures staff are well-versed in regulatory requirements, resident rights, and best practices.
  5. Driving Quality Assurance Initiatives: Regular rounds provide opportunities to assess the quality of care and services provided. Nursing homes can identify areas for improvement and implement quality assurance initiatives to enhance resident outcomes.


Implementing Compliance Rounding

Here are steps to effectively implement Compliance Rounding in a nursing home:

      • Establish a Rounding Team: Form a dedicated team responsible for conducting compliance rounds, including representatives from various departments to ensure comprehensive assessments.
      • Develop a Rounding Schedule: Create a schedule for compliance rounds, specifying the frequency and areas to be assessed. Include all shifts and weekends in your schedule. Consistency in rounds is essential for survey readiness.
      • Utilize Standardized Tools: Design standardized checklists or tools to guide the rounding process, aligning them with CMS regulations and facility-specific policies. CMS Critical Element Pathways and Initial Pool Process Resident Interview/Observation forms serve as excellent compliance tools.When rounding and speaking with staff/residents use open ended questions.
        • Example of staff questions:
          • What things are going well?
          • What is frustrating you with the work or what barriers do you face?
          • What additional resources/tools/equipment do you need?
          • Do any fellow staff members deserve special recognition?
          • What feedback have you heard about recent changes?
        • Example of resident questions:
          • What are your concerns?
          • Have staff been responsive to your needs?
          • Is there anything you need?
          • Do you feel safe?
          • Do you feel well cared for?
          • Does anything worry you?
          • Is your pain being controlled adequately?
          • Do you have any questions?
      • Document Findings: Thoroughly document findings from each compliance round as part of the QAPI process, noting any deficiencies or areas for improvement. Use this documentation to track progress and initiate corrective actions. Report a summary of findings to the QAPI team.
      • Pursue Continuous Improvement: Leverage data collected during compliance rounds to drive ongoing improvement initiatives. Promptly address deficiencies and track progress over time through your QAPI process.


Compliance Rounding is an indispensable approach to survey readiness that empowers nursing homes to provide high-quality care while adhering to regulatory mandates. Through systematic assessment and improvement of care delivery, nursing homes can ensure the safety, satisfaction, and well-being of their residents while minimizing the risk of regulatory penalties. Embracing Compliance Rounding as a standard practice can lead to better outcomes for residents and a more resilient nursing home facility.

Contact Proactive for expert QA support including remote chart review and boots on the ground onsite compliance visits.   Also make plans to join us for upcoming webinar sessions to guide survey readiness:



  1. Centers for Medicare & Medicaid Services (CMS)
  2. Centers for Disease Control and Prevention (CDC) – COVID-19 in Long-Term Care Facilities
  3. Agency for Healthcare Research and Quality (AHRQ) – Health Care Documentation
  4. American Health Care Association (AHCA)
  5. CMS Nursing Home Quality Initiatives
  6. CMS Downloads – Survey Resources (ZIP)




Written By: Angie Hamer, RN, RAC-CT
Clinical Consultant

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