Wondering when surveyors will be at your facility for your annual survey? You’re not alone. This past year has been anything but normal in terms of survey activities. Let’s take a look at the current state of recertification surveys occurring across the nation and data on trends on the most cited deficiencies.
Based on survey records present in CASPER, as of 07/04/2021:
- 20% of the nations nursing homes have had a recertification survey in fiscal year 2021 (Oct 2020-July 2021)
- 70% of nursing homes have had a complaint survey in fiscal year 2021
- The Dallas survey region has completed the greatest number of recertification surveys (27.4% of providers surveyed)
- The Seattle region has completed the least number of recertification surveys (3.5% of providers surveyed)
- Over 50% of the nursing homes in New Hampshire, Illinois, Arkansas and New Mexico have had a recertification survey this year.
- Less than 10% of the nursing homes in the following states have received a recertification survey this year: Connecticut, Vermont, Delaware, Maryland, Georgia, Kentucky, Mississippi, Tennessee, Ohio, Oklahoma, Montana, Utah, California, Alaska, Oregon, and Washington.
- 77% of the nation’s nursing homes have not had a recertification survey in over 15 months.
- 22% of the nation’s nursing homes have not had a recertification survey in over 18 months.
- 1% (20 facilities) have not had a recertification survey in over 36 months.
- National average number of deficiencies per recertification survey = 5.5
- California has greatest average number of deficiencies per survey = 12.3
- The following states have the lowest average number of deficiencies per survey with an average of 2 deficiencies per survey: Vermont, New Jersey, Georgia, Mississippi, South Carolina, Tennessee, and Alaska
- The top 10 cited deficiencies in the recertification surveys completed this year are:
- F880 Infection Control
- F812 Food Procurement, Storage/Prepare/Serve Sanitary
- F761 Label/Storage Drugs & Biologicals
- F689 Free of Accident Hazards/Supervision/Devices
- F656 Develop/Implement Comprehensive Care Plan
- F684 Quality of Care
- F677 ADL Care Provided for Dependent Residents
- F695 Respiratory/Tracheostomy Care & Suctioning
- F686 Treatment/Services to Prevent/Heal Pressure Ulcer
- F758 Free from Unnecessary Psychotropic Meds/PRN Use
Tips for Survey Success
- Facilities should establish processes to use the LTC Survey Pathways tools to routinely to monitor compliance with regulatory requirements. The Infection Control Pathway was recently updated to include a review of COVID vaccination procedures. Since this remains the top cited deficiency on annual surveys and because there are increased sanctions for facilities who receive repeat Infection Control citations, it is critical that you use this pathway to assess your current practices in preparation for your upcoming survey. 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 is recommended for 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 an opportune time 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.
- Consider having the Mock Survey process conducted by a 3rd party for objective results. 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.
Source: Quality, Certification, & Oversight Reports (QCOR)