With 2024 underway, it’s time to focus on what we would like to accomplish in the next 350 days remaining in the year. If you haven’t already created one, consider these goals for your DON New Year’s Resolution list.


  1. Be Survey ready 365 days a year. This is not as difficult to achieve as you might think. One of the easiest ways to accomplish this is to review the clinically related CMS Critical Element Pathways and develop a schedule for using these audit tools each month. You can find them in the “Survey Resources” on the CMS website at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-HomesYou may also consider supplementing the Critical Element Pathways alongside your internal QAPI audit tools, and scheduling systems reviews more frequently in the weeks leading up to your annual survey due date range. Medication administration observations, dining observations, abuse, accidents and resident assessments are all vital areas to review.
  1. Review the new MDS revisions and Medicaid reimbursement revisions for your State (as applicable). With the 10/1/23 RAI updates, there have been many changes to the MDS that have an impact on your facility survey process, QMs, and perhaps your Medicaid reimbursement requirements as well. Some states have gone to a Nursing PDPM component reimbursement method, others are using the Nursing PDPM component combined with additional criteria. Being familiar with the changes and the specific requirements for your State will be vital in ensuring coding compliance and reimbursement validation.  Make sure your MDS staff have had the training they need, and the helpful tools that are available in keeping up with all of the changes. Take a step toward this goal by registering for a 6 week virtual training focused on the Impact on the MDS on reimbursement and QMs beginning February 7, 2024.
  2. Enhance your facility clinical documentation. The New Year continues to see staffing challenges, with frequent staff turnover. Assisting your licensed nursing staff with documentation that is comprehensive, factual, and both legally and regulatorily sound will have significant benefits. Include training, regular auditing and coaching in your action plan. Get a head start on documentation education with the substantive sessions in the monthly Documentation in Depth virtual series. If you missed the falls documentation session in January, don’t worry, complimentary recordings are provided to all sessions when you purchase the entire series.
  3. Be familiar with the current survey trends in your area. Knowing what areas within your facility require focus can often be difficult to determine. One way to do this is to review the survey trends on the https://qcor.cms.gov/index_new.jsp website to identify what the survey teams in your state and region are citing. This website allows you to see the top deficiencies being cited, including IJ deficiencies, as well as the scope/severity and Civil Monetary Penalty (CMP) trends in your area.  This information will help guide your internal audits and determine if any PIPs or action plans might be indicated in areas of particular focus. Consider joining the monthly webinar series Deconstructing Immediate Jeopardy & High-Risk Tags for critical insights into actual IJ deficiencies across the nation and how to avoid them. Recordings of all sessions is included with your series purchase.
  4. Make time for you! As burnout is one of the most common reasons for changeover in DONs, be deliberate in taking action to prevent this from happening. Make sure your Nursing Administrative team has been well-trained in handling situations when they are on-call. Delegate duties to your team as appropriate, and make sure they have the education, guidance, and tools necessary to handle the tasks assigned. Then be sure that your “time off” meets that definition, without interruption or interference with your personal time as much as possible.

Accomplishing even one of these goals will help to contribute to a great 2024. Let Proactive help you to do this with one of our upcoming webinar programs: Impact of the MDS; Immediate Jeopardies; or Documentation in Depth. We wish you a wonderful New Year!




Angie Hamer, RN , RAC-CT
Clinical Consultant

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