On May 11, 2023, the Centers for Medicare & Medicaid Services (CMS) ended certain emergency waivers; put in place during the public health emergency, these waived some F-tag elements that would otherwise have applied during the COVID-19 pandemic. As a result of the ending of these waivers, surveyors will resume following all of the requirements in Appendix PP – Guidance to Surveyors for Long-Term Care Facilities of the State Operations Manual as they investigate compliance with F-Tags (F540 – F949). Furthermore, oversight and enforcement of the regulatory climate continues to intensify. Recently, CMS has added the March 2023 revised guidance strengthening enforcement of infection control deficiencies, issued clarification of phase 2 and guidance on phase 3 requirements of participation, strengthened oversight of nursing home complaints and facility reported incidents (FRIs), and revised the special focus facility (SFF) program. With these changes already released and more likely to come, facilities should implement a survey preparedness program that the Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) committee governs, to ensure the facility meets evolving requirements.
Survey preparedness program defined
A “survey preparedness program” is a methodical, proactive approach to compliance that includes a set of planned activities to self-investigate and take corrective actions to address any gaps in compliance. It also incorporates processes that ensure the facility consistently delivers high quality care and services, in accordance with regulatory requirements. For example, daily clinical rounds are often a component of survey preparedness programs. An essential tactic for survey preparedness, such rounds enable the director of nursing services (DNS) or nurse manager to:
- Connect with staff, residents, and families;
- Gain and share valuable information;
- Reinforce consistency of standards and compliance; and to
- Model clinical leadership behaviors and skills.
The difference between a survey preparedness program and a mock survey
Some facilities annually conduct a mock survey to evaluate the facility’s compliance and to prepare for the standard survey. A mock survey adds value by allowing leaders to see the facility from the perspective of a survey team, which helps leaders anticipate instances of potential noncompliance.
While mock surveys are helpful, they present a limited snapshot of the facility’s compliance at one point in time. This narrow timeframe risks missing subtle yet significant gaps in compliance that can occur after the mock survey . For example, if the mock survey concludes in January but the DNS position turns over in February, the facility can be in a state of flux until a new DNS stabilizes clinical operations. In this instance, the facility may be unaware of gaps in compliance that occur during this transition period. A survey preparedness program could identify those gaps by continuing the program’s scheduled activities, overseen by the QAA/QAPI committee.
Unlike the mock survey, a survey preparedness program systematically achieves and maintains a state of survey preparedness. With an intentional and methodical approach to maintaining compliance, facilities can implement systems that withstand the scrutiny of the survey process throughout the year.
Four components of a successful survey preparedness program
To implement a survey preparedness program successfully, the DNS must ensure that the program includes the following four components. These components will provide long-lasting internal oversight that aligns with surveyor methods to ensure year-round compliance.
Commitment of the QAA/QAPI committee
The first component of a successful survey preparedness program is the QAA/QAPI committee’s commitment to survey preparedness. The committee must embrace the goal to provide excellent care in a manner that complies with the regulatory requirements. Doing so requires the QAA/QAPI committee to adopt the perspective of eliminating non-compliance rather than defending actions that could be or lead to non-compliance. The time for making a case that the facility took appropriate actions is during the survey; before then, the QAA/QAPI committee should focus on the need to seek out potential noncompliance, correct it, and prevent it from occurring.
As with any change, the QAA/QAPI committee should expect challenges in achieving this goal. Common obstacles include time constraints, uncertainty about doing things a different way, and unforeseen issues that complicate fully executing the program. A QAA/QAPI committee that is committed to fully deploying a survey preparedness program steadfastly works through these challenges and dedicates the resources necessary.
Development and execution of a detailed survey preparedness plan
The second component of a successful survey preparedness program is a detailed plan that articulates the actions that will be taken throughout the year, when those actions will be taken, and by whom. This level of detail is essential because it provides clarity to all involved, allowing them to prepare accordingly and work in harmony to achieve the goal of compliance. As the QAA/QAPI committee and individual leaders deploy the actions, the survey preparedness plan will likely require adjustment as the team learns more efficient and effective ways to do things. For example, the initial plan may call for quarterly observations of infection control and prevention care, but as the infection preventionist (IP) integrates the observations into his or her workflow, the plan may change to doing them monthly.
Methods that mimic the standard survey
For a successful survey preparedness program, the third component requires the facility to adapt the methods and tools surveyors use to investigate compliance during the standard survey. Mimicking the survey process prepares the facility to withstand the scrutiny of the standard survey as outlined in the Long-Term Care Survey Process Procedure Guide. For example, the QAA/QAPI committee should select a sample of residents monthly that the survey team would likely include in its sample of residents and investigate compliance by conducting medical record reviews and audits, interviews, and observations of care for those sampled residents. The AAPACN Survey Preparedness Program provides a plan to help the QAA/QAPI Committee determine the timing and focus of program activities. In addition, the survey preparedness program should incorporate the investigative protocols in Appendix PP and utilize the long-term care critical element pathways (located in the Survey Resources folder under the Nursing Homes page on the CMS website). These pathways provide not only guidance on conducting an investigation but also interpretations of the regulations and explanations of the elements of noncompliance surveyors use to cite a deficiency. This knowledge is invaluable when deciding what actions the facility should or should not take to achieve and maintain compliance.
Involvement of all staff in process feedback and changes
The necessary fourth component of a successful survey preparedness program is the participation of each staff member in process improvement and consistency. Just one instance of performing a task in a manner inconsistent with the facility’s policy and procedure can provide surveyors the evidence needed to cite a deficiency. Staff who must follow processes, as well as those in leadership, including the QAA/QAPI committee, must communicate how processes are working in practice. This feedback is important when things are going smoothly, but even more so when processes are not working as intended. Involve staff with firsthand experience in designing or modifying the processes that aren’t working well and causing noncompliance. By seeking staff input, leadership and staff can work together to design processes that always facilitate compliance. Furthermore, this level of involvement nurtures a deeper level of commitment and loyalty to the facility, as well as a desire to do an excellent job all the time.
Additional resources to assist with survey preparedness
AAPACN offers several resources to assist the QAA/QAPI committee with survey preparedness. See the following:
- Survey Preparedness Program – This new AAPACN product in PDF format walks the DNS and the QAA/QAPI committee through setting up a survey preparedness program and provides in-depth resources and tools for constant survey readiness.
- Government Source Documents – AAPACN provides quick access to regulatory documents.
- Survey and Regulatory Compliance Updates– AAPACN offers content to ensure members stay up to date with survey and regulatory compliance changes.
- How SNFs Can Address CMS’s New Enhanced Enforcements for Infection Control Deficiencies– In this LTC DON Chat podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, AAPACN curriculum development specialist, discuss the new enhanced enforcements for infection control CMS released in March 2023 and their potential impact on skilled nursing facilities (SNFs).
- How to Navigate and Prioritize Current Regulatory Changes for Nurse Leaders – In this LTC DON Chat podcast, Amy Stewart, vice president of education and certification strategy for AAPACN, and Alexis Roam, AAPACN curriculum development specialist, discuss how to handle several different regulatory changes nurse leaders are navigating right now.
- F-Tag Library – This new AAPACN on-demand series includes several presentations that assist the learner to understand the nuances of different F-tags and provides steps to attain and maintain compliance with federal regulations. It includes areas to review for compliance and education for staff, as well as helpful information for leaders starting out in their role and five newly developed tools.
For permission to use or reproduce this article in full or in part, please complete a permissions form.