Article contributed by AAPACN Business Partner Strategic Healthcare Programs
By Henry R Saucier, LNFA
When those rolling briefcases pass through your facility’s front entrance, that familiar surge of anxiety is universal among post-acute care professionals. But what if you could anticipate what surveyors will examine before they arrive? The truth is, you can—and the roadmap is already in your hands.
As Will Rogers once observed, “Good judgment is the result of experience, and experience is the result of bad judgment.” In survey preparation, your facility’s history isn’t just a record of the past, it’s a predictor of what’s coming. In this article, we’ll highlight nine critical areas that show how data can serve as your crystal ball for survey success.
Understanding the Surveyor’s Playbook
Before state surveyors step foot in your facility for the annual survey, they’ve already done their homework. They’re analyzing the same data you have access to:
- Historical deficiency patterns from your facility
- Recent citations and findings
- Past survey results and trends
- Quality Measure (QM) alerts and triggers
- Staffing data documented in PBJ (Payroll-Based Journal) reports
- Regional deficiency patterns from surrounding facilities
This isn’t a guessing game for surveyors. It’s a methodical, data-driven approach to identifying potential compliance issues. The question is: Are you using the same strategic approach to prepare?
The Data You Already Have: Nine Critical Areas to Review
1. Historical and Recent Deficiencies
Your facility’s deficiency history tells a story. Repeated citations in specific areas signal systemic issues that require more than quick fixes. Review both historical patterns and recent findings to identify:
- Areas where your facility has struggled consistently
- Whether corrective actions have been truly effective
- Emerging trends that might indicate new vulnerabilities
2. Past Survey Outcomes
Each survey provides valuable intelligence. Examine not just what was cited, but:
- Which resident populations were targeted for investigation
- What documentation issues arose
- How surveyors approached specific clinical concerns
- What questions staff struggled to answer
3. Quality Measure Reports and Triggers
QM reports flag residents who meet specific risk criteria. These same reports guide surveyors toward residents who warrant closer examination. Pay particular attention to:
- Residents with multiple QM triggers
- New or worsening quality indicators
- Areas where your facility’s performance differs significantly from state or national averages
4. Staffing Patterns and Discrepancies
Your PBJ data reveals more than just compliance with staffing requirements. It shows:
- Periods of instability that may have affected care quality
- High turnover patterns that could impact care consistency
- Gaps in coverage that surveyors may correlate with adverse events
5. Interviewable vs. Non-Interviewable Residents
Here’s a critical insight many facilities overlook: Non-interviewable residents absolutely have a voice and it’s written in their medical record. Every note, assessment, and care plan tells their story. For these residents, your documentation must speak for them, accurately reflecting:
- Historical data and baseline functioning
- Changes in condition with appropriate follow-through
- Prior assessments that demonstrate clinical progression and care planning accuracy
6. High-Risk Residents
Identify residents who are most vulnerable or who have complex care needs:
- Those with multiple comorbidities
- Residents with recent hospitalizations or ER visits
- Individuals with behavioral health needs
- Those at risk for pressure injuries, falls, or infections
7. Your Sample Pool
Surveyors create their sample pool using your data. Anticipate which residents are likely to be selected by reviewing those with:
- Multiple QM flags
- Recent changes in condition
- Complex medication regimens
- Care planning challenges
8. Regional Trends
You don’t exist in a vacuum. Reviewing deficiency patterns in your county or region through tools like the QMS Mock Survey tool helps you understand:
- What issues surveyors are finding in similar facilities
- Emerging regulatory focus areas
- Common documentation pitfalls in your area
9. MDS Accuracy: The Highest-Stakes Area
With revised CMS guidance taking effect in 2025, MDS accuracy has never been more critical. Tag F641 (Accuracy of Assessments) remains one of the most frequently cited deficiencies, appearing in approximately 17% of recertification surveys.
The stakes have been raised significantly: If surveyors identify a pattern of inaccurate MDS coding—defined as three or more residents with discrepancies—they are now directed to refer the matter directly to the Office of Inspector General (OIG) for investigation of potential falsification. This bypasses previous channels and fast-tracks your facility into serious scrutiny.
Areas of particular concern include:
- Functional status coding (especially Section GG)
- Diagnoses without adequate documentation (particularly psychiatric diagnoses like schizophrenia that appear suddenly on assessments after years of absence)
- Pain assessment and management documentation
- Behavioral health indicators
- Restraint use
- Hospice services
From Reactive to Proactive: Building Your Survey Prep Strategy
Being “state-ready” every day is the ideal, but we work in the real world. Facilities face constant challenges: staffing shortages, grieving families, complex clinical situations, and the daily unpredictability of healthcare. You can’t anticipate everything, but you can use history strategically.
Create a systematic review process:
- Monthly Data Review: Don’t wait for survey notification. Review your QM reports, MDS accuracy audits, and care planning documentation monthly.
- Quarterly Trend Analysis: Every quarter, analyze patterns in incidents, complaints, weight loss, pressure injuries, falls, and infections.
- Mock Surveys: Conduct focused reviews using the same criteria surveyors will use. Be honest about what you find.
- Interdisciplinary Preparation: Survey prep isn’t just the MDS coordinator’s responsibility. Engage nursing leadership, dietary, activities, social services, and therapy in regular reviews.
- Documentation Audits: Ensure that what’s documented in the medical record matches what’s coded on the MDS and reflected in the care plan. These documents must tell a coherent, consistent story.
The Non-Interviewable Resident Story
Let’s focus on a population that’s often misunderstood: non-interviewable residents. Many teams breathe a sigh of relief when these residents aren’t selected for interview, but that relief is often misplaced.
When a surveyor reviews a non-interviewable resident’s chart, they’re looking at:
- Historical data: Does it show appropriate baseline assessment?
- Changes in condition: Were they recognized promptly? Was there appropriate follow-through?
- Care planning: Does it reflect current needs and show regular evaluation?
- Prior assessments: Do they demonstrate clinical accuracy and progression of care?
Your documentation must speak for these residents. Every missed assessment, every delayed response to a change in condition, every care plan that doesn’t match the current clinical picture—these tell a story, too. Make sure it’s the right story.
Tools for Precision
SHP for Skilled Nursing offers Survey Prep tools like the MDS Indicator Rate Report, often nicknamed the Crystal Ball Report, which proactively selects the residents that are high risk for Sample Pool selection using the CMS Surveyor Criteria. This report crosswalks your team to the residents (those that will be interviewed, observed, or have their records reviewed) with the CMS Critical Element Pathway forms available in the system.
The Bottom Line: Find Your Data Before It Finds You
The data that surveyors will use to prepare for your annual survey is already available to you. The difference between a facility that’s caught off-guard and one that’s genuinely prepared often comes down to one thing: who reviewed the data first.
As post-acute care professionals, you understand that quality care requires constant vigilance, clinical expertise, and attention to detail. Survey preparation demands the same approach. Use your history, analyze your data, identify your vulnerabilities, and address them proactively.
The surveyors will come with their briefcases and their checklists. But if you’ve done your homework, you’ll already know what they’re looking for—and you’ll be ready with the right answers.
About Strategic Healthcare Programs: SHP partners with post-acute care facilities to transform data into actionable insights. Our comprehensive suite of tools helps nursing teams identify survey risks, optimize MDS accuracy, improve quality measures, and maximize reimbursement—all while keeping resident care at the center of everything we do. Learn more about how SHP can support your survey preparation efforts and ongoing compliance at www.shpdata.com.
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