Navigating Nursing Home Survey Trends Into the New Fiscal Year

As a new fiscal year begins, it’s the perfect time to dive into survey trends we’ve witnessed across the nation in the past year. These these trends can serve as a guide to preparations for upcoming surveys.  For those eagerly awaiting the survey team’s arrival, these insights will help you steer the ship through the ever-shifting regulatory currents.

Notable trends in survey activity based on survey records in CASPER, as of 10/08/2023 for Fiscal Year 2023 (10/01/22-09/30/23) include:

Survey Activity

• 57.6% of the nation’s nursing homes had a recertification survey
  • Region V (Chicago) completed the greatest number of recertification surveys (70.3% of providers surveyed)
  • Region II (New York) had the lowest percent of facilities with recertification surveys completed (39.7% of providers surveyed)
  • Kentucky has the lowest percent of facilities with recertification surveys completed (7.9%)
  • New Hampshire has the highest percent of facilities with recertification surveys completed (94.6%)
• 80% of nursing homes had a complaint survey
  • Region IX (San Francisco) conducted the greatest number of complaint surveys (93.9% of providers)
  • Region VIII (Denver) had the lowest percent of facilities with complaint surveys conducted (62.9% of providers)
  • Delaware has the lowest percent of facilities with complaint surveys completed (0%)
  • Rhode Island has the highest percent of facilities with complaint surveys completed (98.7%)
• 50.1% of nursing homes had an Infection Control Survey completed.
  • Region VI (Dallas) conducted the greatest number of infection control surveys (69.2% of providers)
  • Region IV (Atlanta) had the lowest percent of facilities with infection control surveys conducted (39.6% of providers)
  • Tennessee has the lowest percent of facilities with infection control surveys completed (31.1%)
  • Texas has the highest percent of facilities with infection control surveys completed (82.3%)

Overdue Recertification Surveys

• 29.9% of the nation’s nursing homes have not had a recertification survey in over 15 months.
  • Region VI (Dallas) has the lowest percentage of facilities who have not surveyed in over 15 months (12.3%)
  • Region II (New York) has the greatest percentage of facilities who have not surveyed in over 15 months (51.5%)
  • Kentucky has greatest percent of facilities who have not surveyed in over 15 months (89.1%)
  • Hawaii, Louisiana, Nevada, Puerto Rico, and South Dakota each only have one facility in the state who has not surveyed in over 15 months.
• 21.3% of the nation’s nursing homes have not had a recertification survey in over 18 months.
  • Kentucky has greatest percent of facilities who have not surveyed in over 18 months (84.4%)
• 11.3% of the nation’s nursing homes have not had a recertification survey in over 24 months
• 5.1% (757 facilities) have not had a recertification survey in over 36 months.
  • Kentucky has the greatest number of facilities who have not surveyed in over 3 years (63.3%)

Average Number of Deficiencies

• National average number of deficiencies per recertification survey = 7.1
  • Maryland has greatest average number of deficiencies per survey = 23.0
  • Mississippi has the lowest average number of deficiencies per survey with an average of 4.0 deficiencies per survey

Top Citations

The top 10 cited deficiencies in the recertification surveys completed this year are:

1. F812 Food Procurement, Storage/Prepare/Serve Sanitary
2. F880 Infection Control
3. F689 Free of Accident Hazards/Supervision/Devices
4. F656 Develop/Implement Comprehensive Care Plan
5. F761 Label/Storage Drugs & Biologicals
6. F684 Quality of Care
7. F695 Respiratory/Tracheostomy Care & Suctioning
8. F677 ADL Care Provided for Dependent Residents
9. F657 Care Plan Timing and Revision
10. F758 Free from Unnecessary Psychotropic Meds/PRN Use

Terminated Providers

• 172 facilities providers were terminated over the year.
• Texas had the most facilities (14) with provider agreements terminated.
• Ohio, Wisconsin and Iowa each had 11 providers terminated.

Tips for Survey Success

1. Stay Informed: Keep up with the latest regulations and guidelines. The more you know, the better you can prepare.
2. Regular Self-Assessment: Conduct routine internal assessments using LTC Survey Pathways tools. It’s an excellent way to monitor compliance and spot potential issues.
3. Mock Surveys: Don’t forget the mock surveys! These dry runs help you evaluate your systems, processes, and staff readiness.
4. External Perspectives: Consider external mock surveys from a reputable consulting firm to get an objective viewpoint and identify any areas that might need attention.
5. Proactive Planning: Develop performance improvement plans to address any concerns identified during routine monitoring or mock surveys.
6. Stay Current: With Infection Control remaining a top citation, make sure you’re up-to-date with the latest protocols, especially regarding COVID-19.
7. Expert Help: If you need guidance and support, consulting services like Proactive LTC Consulting can be invaluable in preparing for surveys.

With an ever-changing regulatory landscape, staying informed and proactive is the key to success. Use the insights from this past year’s survey trends as a roadmap to guide you through the challenges that lie ahead.

Contact Proactive to schedule a mock survey, for assistance in developing a plan of correction, for directed inservice training, or help in the IDR process.

Source: qcor.cms.gov (CASPER 10/08/2023)