Nursing Home Social Services Reference/State Surveys/What and Why of State Surveys

Overview What they are... "Surveys" are what the CMS Regulations call Nursing Home and Skilled Nursing Home facility audits. These surveys are used to respond to complaints, assess any changes in facility performance after important changes in ownership or the highest levels of facility management, or review the general performance of the facility. The objective is to be sure that the facility meets the requirements of Medicaid and Medicare for re-imbursment of care to residents. These surveys are accompanied by local (county or municipal) audits of the facility for fire and mechanical safety when at least annual. Surveys may also be conducted to assess the success of and compliance with corrections planned to answer deficiencies found in the previous survey. The surveys are conducted under the federal rules for CMS (Title 42) by employees or agents of the state CMS organization. Facilities are compared across a state based on a code number and a severity of the finding. Each deficiency is noted by a code that refers to the area in which the deficiency was identified. Next the surveyors review the scope of the deficiency. Is it limited to a single resident or is this a wide spread issue. Then each deficiency is lastly assessed for the level of actual or potential harm to residents. The scope and severity have a letter associated with them that range from A as isolated and least dangerous up to L as widespread and immediately jeopardizing to the health and safety of resident(s). Each finding and its deficiency score is commonly called a tag. Codes that start with 'F' are federal requirements, other letters indicate other governmental requirements. Survey Deficiency Score: SFF Weights for Different Types of Deficiencies ScopeSeverityPoints (Deficiency Score)IsolatedWidespread / Immediate jeopardyJ: 50 pts; K: 100 pts; L: 150 ptsActual harm (not immediate jeopardy)G: 10 pts; H: 20 pts; I: 30 ptsNo actual harm, potential harm > minimalD: 2 pts; E: 4 pts; F: 6 ptsNo actual harm, minimal potential harmA: 0 pts; B: 0 pts; C: 0 pts When do they happen.... These surveys must be done within the 15 months (to the day) of the completion day of the previous survey. There is also a statewide average of 12 months that must also be met by the state CMS agency. (See 42CFR488-308a.) Surveys may also be completed as the state receives complaints by residents, family members, community members, and/or staff. Process of the Survey The surveyors will arrive at the Nursing Home during business hours to begin the survey. It is usually a small team of 3-4 with a lead surveyor assigned to oversee processes. They will setup their "base" in a quiet, private area like a meeting room as they conduct their work. Surveys can take anywhere between 1-4 days, not including follow-up visits. During the survey they will interact with residents and follow up with appropriate departments and staff. It is the responsibility of the Nursing Home to respond in a timely manner to all requests for documents and other information. Review of the Results of the Survey Once the survey has been concluded, the results are compiled and then delivered to the Nursing Home as a document. The surveyors also will review the results with leadership, usually the Director of Nursing and the Administrator. After the Survey Following the survey the Nursing Home management will share the results with department staff and indicate next steps if any. If there are areas the Nursing Home needs to improve or respond to, the appropriate departments will create a Plan of Correction (PoC) that will be reviewed by management (and/or corporate staff). These PoCs will be sent to the state CMS to be approved. If any of the PoCs are not approved, a statement indicating what is deemed incomplete or inaccurate in the PoC. If a POC is rejected by the state, the nursing home staff create a new PoC and repeat this process until the PoC is accepted. Department leaders will then ensure that the accepted PoC is implemented. The survey document is printed, bound and placed where the public can look at it. Possible Follow-up Survey The CMS surveying team will decide, based on the severity and/or number of tags a nursing home has received that a follow-up survey is required. This will then be executed with a few months of the original survey. This does not reset the calendar for the next survey. Follow-up Surveys may also occur in response to a complaint survey. This foolw-up is again at the discretion of the state CMS survey team.