Year-Round Survey Readiness

Year-Round Survey Readiness

Regulatory changes have been plentiful for the long-term care profession over the past five years—with operators persevering through the COVID pandemic, changes to government funding policies, and significant revisions to Appendix PP to name a few. Each policy revision adds to the substantial task of achieving successful survey outcomes. Last-minute survey preparation is insufficient; instead, facility leaders must implement a robust plan for year-round survey readiness.

The key to a survey ready strategic plan is to divide and conquer to address the many moving parts that culminate in a positive annual survey. Each department and team member is integral to the ongoing monitoring and audit processes necessary for year-round readiness. All facility systems must be scrutinized using protocols for care and service observations and formal documentation reviews. The CMS Critical Element Pathways (CEPs) should be the essential primary audit tools. Because the CEPs are utilized by the state agency during the survey, they are the best guide for conducting the observations, record reviews and interviews in review of each facility process. In this way, the facility will be examining their performance with the same information available to the survey team.

While numerous, the CEPs do not cover all areas of care in the facility. Additional audit tools, checklists, and observation worksheets will be necessary to cover each facet of long term care service that could potentially impact surveyor findings. For example, many facilities are not aware that the stove and fryer in the kitchen must have markings on the floor designating exact placement/positioning of these appliances, so that they can be aligned correctly under the overhead fire prevention system in the event they must be moved for some reason. This requirement is not included on the Kitchen CEP, and no CEPs are in place for Life Safety.

In addition to strong internal QA systems, 3rd party Mock Surveys are an excellent means of assessing survey readiness in combination with year-round audits and observations implemented to ensure year-round survey preparedness. An established cycle of reviews throughout the year will provide continuous scrutiny to assist the facility in identifying issues when they are minor and before they can lead to negative outcomes and/or survey deficiencies.

Next Steps:

• • Start your strategic plan for year-round survey readiness. Contact Proactive to schedule a mock survey.
  • Make plans to join us on 8/27/25 for the Survey Prep and Post Survey Elements webinar series that includes considerations for week-by-week checklists that will guide your facility through an ongoing survey readiness process.
  • Access Proactive’s complete guide to year-round survey readiness with the Survey Ready Toolkit and fast forward preparedness for positive Survey outcomes
  • Focus on the most frequently cited deficiencies in nursing homes with on-demand training for your team. Check out recorded sessions of the 20254 Survey Smart—LTC Deficiency Trends & Solutions series

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