Now that annual surveys have resumed, long-term care facilities should be prepared for the first Annual survey they may have had in a very long time. Consider completing a survey readiness checklist as part of your facility’s self-evaluation. Use this sample checklist as a template to begin your review….

Consider reviewing these high-risk areas for deficiencies as part of your survey-ready preparations:

      • Review the previous survey results and the plan of correction. Has that plan of correction (PoC) been completed?   Is compliance being maintained with the areas addressed by the PoC?  Does any follow up auditing need to be completed?
      • As infection control concerns continue with the ongoing pandemic, F880 tags related to Infection Prevention are sure to be a priority with surveyors. Review Infection Prevention and Control policies and procedures to ensure that an accurate, complete system is in place for tracking, trending and reporting infections. Include a review of staff competencies on types of isolation, donning and doffing PPE, correct hand sanitation, etc.
      • F684 Quality of Care is a common area for deficiencies. Complete a formal clinical system review to include Hospice residents, dialysis, wounds, pain, changes of condition, and weight loss.
        • Validate those necessary interventions are care planned and implemented
        • Verify that education and training of staff has been completed, along with staff competencies in relevant care areas;
        • Ensure that appropriate diagnoses are in place for restraint use and catheters
        • Validate that residents with tube feedings have all the needed monitoring interventions implemented;
        • Audit to ensure that all a smoking assessment has been completed for smokers at least quarterly?
        • Evaluate to be sure that the Influenza, pneumococcal, and COVID vaccination status is up-to-date for all residents
      • Review Quality Measure (QM) triggers> 75% and audit for care plan accuracy and appropriate clinical documentation.
        • In compliance with F656, Care plans should print a clear picture of resident preferences, choices and goals with measurable objectives and real time interventions in place.
        • Validate that the MDS accurately captures resident clinical conditions AND whether triggered CAAs are care planned if necessary.
        • Ensure that documentation in the medical record is present showing the resident/family are involved in the care planning process
      • Update the facility assessment and implement any needed interventions to prevent foreseeable hazards or resident injuries. Identify risk factors for potential accidents, and implement individualized interventions to reduce risk factors and monitor for effectiveness.
      • Audit medication carts and med storage rooms weekly as F761-Label/Store Medications and Biologicals is a common tag.
        • Are open containers labeled with the expiration date? Are any medications/lab supplies expired? Eye and ear medications cannot be stored in the same bin, they must be separated, as well as liquids and powders. Scheduled classes of medications must be under a double lock.
        • Monitor med pass frequently to ensure staff are not leaving the medication cart unlocked when unattended and the computer screen is not visible to any passersby.
      • Review all wound documentation:
        • Are the wounds community or facility acquired?
        • What type of wound does the resident have-arterial, venous, diabetic, pressure? Are preventative measures in place, is the current treatment plan effective, and are there weekly measurements to show clinical improvement or decline?
        • Review any pertinent nutritional information interventions such as supplements, extra protein, or vitamins and ensure that they are care planned.
        • Verify that any pertinent lab data related to wounds, such as cultures, is present in the medical record.
        • Pain should be addressed clearly-whether present or absent as well as interventions to alleviate. Use the CMS critical element pathway F686 Treatment/services to prevent/heal pressure ulcer as an audit guide to ensure the appropriate interventions and documentation are present in the medical record.
      • Tag F758 Unnecessary Psychotropic medications is another top ten citation.
        • Audit residents on psychotropics for documentation of appropriate dose, duration, and clinical recommendations for continued use.
        • Ensure gradual dose reductions (GDR’s) are attempted when clinically indicated. If a GDR fails or is clinically contraindicated, then the physician must have documentation present to address any potential adverse consequences, including risks and benefits. GDR’s must show attempts in two separate quarters and then annually, with non-pharmacological approaches attempted and documented.
        • All prn psychotropic/antipsychotics must have a duration of 14 days or less. If the MD renews after that time, then documentation must be present from the physician stating the rationale and determined duration of the medication.
      • Review the kitchen thoroughly, as F812 is a commonly cited tag. Audit for compliance with food and safety regulations including, but not limited to expiration dates visible, properly sealed and stored food, temperature logs complete and accurate, etc.
      • Review life safety and emergency preparedness information, including fire drills, door inspections, the sprinkler system and fire alarm.
        • Inservice all staff on commonly asked questions during the survey process. For example, when it comes to your Disaster and emergency preparedness plan, do all staff know what to do?
      • Complete a weekly review of your survey binder to ensure that is up to date.
      • Schedule a third-party mock survey to be conducted. Mock surveys are extremely valuable in identifying deficiencies non-compliance concerns or areas that need improvement within the facility. Any identified concern should be addressed by the QAPI team and a plan of correction developed to correct the problem area.

By using a survey readiness checklist, the facility can thoroughly and efficiently review the most critical areas that are often a focus during the Annual Survey. Join us on August 10, 2022 for Risk Management for the DON  and again on August 31, 2022 for Survey Readiness for the DON as part of  the Dynamic DON Series, you will discover additional tips and strategies for survey readiness for the Nursing Department. You may also make plans to join us for the year long Survey Success-Avoiding Top Citations series on the first Tuesday of each month for analysis of the top citations in the nation and strategies to avoid them. On-demand access to past sessions is available here.


Co-written By: Michele Harrison, RN & Janine Lehman, RN, RAC-CT, CLNC

Learn more about the rest of the Proactive team.