November is just around the corner and CMS has been busy developing resources related to the upcoming implementation of the new nursing facility/skilled nursing facility (NF/SNF) survey process. The target date of implementation is November 28th, 2017.
The new survey process was designed to incorporate aspects of the traditional survey and the QIS survey processes. CMS contends that the implementation of the new survey process will result in meeting their following objectives:
- All facilities will be surveyed using standardized process
- Strengths form the Traditional and QIS survey were deployed.
- New survey process uses new innovative approaches.
- More effective and efficient survey process.
- Provides a balance between structure and surveyor autonomy.
Like the QIS survey, surveyors will be utilizing computers to input their findings to assist in the resident selection process, analyze data and aid in determining survey outcomes.
Prior to beginning the actual facility survey, the survey team will engage in offsite survey preparation tasks. These activities will include, but not limited to, a review of prior survey outcomes, complaints, self-reports and any applicable waivers. A survey packet will be created and survey team members will be provided with their unit and mandatory task assignments.
The New Survey Process
The new survey process will consist of 3 parts: (1) The Initial Pool process, (2) the Sample Selection and the (3) the Investigation process. In addition, the survey team members will also have pre- and post- survey tasks (i.e., pre-survey prep, entrance conference and exit conference). Let’s take a quick look at each of these components.
Upon arriving at your facility, the survey team leader will conduct a brief entrance conference. During this conference, the team leader will provide the facility with an Entrance Conference Worksheet that will detail the information and documentation that should be provided to the survey team and the timeframe in which it should be provided (e.g., immediately, 1 hour, 4 hours etc.). Nursing facility provides can be proactive and have much of this information readily available in a “survey binder”.
Note that a formal tour of the nursing facility will no longer be a routine part of the survey process, however a brief visit to the kitchen will be conducted. The remaining members of the survey team will go immediately to their assigned units to begin the survey.
Initial Pool Process:
Surveyors will conduct an initial review of approximately eight residents each. This review will be comprised of resident/family interviews, observations and medical record review. The Initial Pool Process will take 8 hours on average to complete required interviews, observations and screening.
Sample Selection Process (Part 2):
Upon completion of the initial pool process, part 2 will begin. In this phase, the survey team will meet to review and analyze information collected and determine the final sample to review during the remaining part of the survey. The total number of residents selected will be based on facility census and will equate to approximately 20% of the facility census. In addition, discharged residents will also be selected for a closed medical record review.
The investigative process is where additional observations and reviews will be conducted. The surveys will expand on any areas of concern that may have been identified. During this part of the survey, the survey team members will conduct 9 mandatory tasks as well as the required closed record reviews. The survey team will use CMS developed Critical Element (CE) Pathways as well as Appendix PP of the State Operations Manual (SOM) to assess compliance with current Requirements of Participation (ROPs).
At the completion of all survey tasks, the survey team leader will conduct an exit conference. During this exit conference the surveyor will relay preliminary survey findings and potential areas of deficient practice and allow for nursing home providers to ask questions or provide any additional information that may be warranted.
As part of the new survey process, the surveyors will be required to complete nine mandatory tasks for each survey conducted. These mandatory tasks include a review of the following target subject areas:
- Infection control
- SNF beneficiary protection notices
- Kitchen observation
- Medication administration and storage
- Resident council meeting
- Staffing review
CMS has created CE Pathways to assist surveyors in completing these mandatory tasks. Additional CE Pathways are also available for other clinical, regulatory reviews that may be conducted. Currently, there are a total of 41 different CE Pathways available.
It would be beneficial for nursing facility providers to become familiar with each of the CE Pathways and determine compliance with the regulatory requirements outlined in each Pathway as part of your survey readiness program.
New Facility Matrix
CMS has also been busing revising the Facility Matrix (CMS 802). This document will need to be completed for new admissions (within the past 30 days) at the onset of the survey. A complete Facility Matrix, to include all current residents, will be required within four hours.
Providers should become familiar with the various clinical conditions that will be captured on the new Facility Matrix. Providers should also become familiar with the Facility Matrix completion instructions. If you currently have a CMS 802 report available in your MDS software system you will want to make sure that this is updated as well.
As part of the revised ROPs, CMS underwent a complete revision of the F-tag numbering system. In addition to renumbering, some of the F-tags were split into multiple subparts. To assist nursing facility providers to become better acquainted with the new numbering system, CMS has created a crosswalk of old F-tags to new F-tags.
Educational resources and additional information, including the new CE Pathways, Entrance Conference Worksheet, F-tag crosswalk, Facility Matrix and the updated Appendix PP can all be located here.
CMS is preparing for the new survey rollout, are you?
Continue to keep up with revisions affecting your organization and register for our Part II of the “Final Rule” Phase 2 Webinar Series with McKesson and Pathway Health.