With the challenges of 2020 dictating the priority focus for most, the New Year presents the opportunity for goal setting and strategic planning that includes 5-Star Improvement and positive survey outcomes. What should your 2021 strategic plan for survey success include?

2020 was anything but normal in terms of survey processes and 5-Star rating system updates. In March, the Centers for Medicare & Medicaid (CMS) suspended routine surveys and throughout the year, surveys were primarily focused infection control surveys. As a result of the suspension of routine surveys, CMS held the Health Inspection Rating domain of the 5-Star rating system constant.   In August, CMS authorized states to resume performing routine surveys as soon as they have the resources to do so. While the COVID­19 Public Health Emergency (PHE) has still hindered States’ ability to completely resume all inspections, many states have been able to conduct additional surveys. As a result, this month, CMS announced that they will resume calculating nursing homes’ health inspection ratings on Jan. 27, 2021 and the findings from the focused infection control inspections will be used in the calculation the same way as findings from complaint surveys are used in the 5-Star Rating System. As a result, many facilities will see a decline in their 5-Star Rating at the start of the new year and will need to re-evaluate their plans for 5-Star improvement and strategies for improving survey outcomes on future surveys.

Infection Control Continues to Take Center Stage

We know that focused infection control survey will continue into 2021 and there will be an increased emphasis on infection control during annual surveys. CMS has combined the COVID-19 focused infection control survey with the infection prevention, control, and immunization pathway used on the recertification survey. There will now be one pathway that can be used for both recertification and focused infection control surveys. As you know, both annual surveys and complaint surveys, including focused infection control surveys, can have a significant impact on your overall 5-Star Rating.

Tips for Survey Success

  • Facilities should establish processes to use the LTC Survey Pathways tools, including the Infection Control Pathway, to routinely to monitor compliance with regulatory requirements. 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.
  • A mock survey is also an invaluable process that should be used by all facilities. 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.
  • To help guide your action planning, plan to join us in January for the first webinar session in our 2021 Cultivating LTC Leaders series, “Mastering the Long-Term Care Survey Process Part 1: Survey Success”. This session will overview the Long-term Care Survey Process including guidelines for determining Immediate Jeopardy and survey procedures and help you to apply strategies for survey success. Register Here.

Proactive Medical Review 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.


Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, Proactive Medical Review

Click here to learn more about Shelly and the rest of the Proactive team.