Background
To ensure senior care providers are meeting regulatory compliance, The Centers for Medicare & Medicaid Services (CMS) audits nursing centers and facilities through an unannounced annual state survey process. In 2022, CMS identified over 123,000 deficiencies for skilled nursing centers and nursing facilities, which resulted in over $176 million dollars in civil monetary penalties (per diem).
In the fall of 2022, a government-owned skilled nursing facility (SNF) in western Wisconsin neared their survey window. Due to COVID-19 and the subsequent delays in annual inspections, the SNF had not undergone an inspection since early 2019. In that time, the community had undergone a leadership change, and the new Executive Director had not yet led a community through an annual inspection.
Solution
With an inexperienced leader and several years since their last inspection, in an effort to ensure they were prepared for the upcoming state survey, the community hired Health Dimensions Group® (HDG®) to conduct a quality assurance and Positive Review and Evaluation Process (PREP), or mock, survey.
PREP surveys position SNFs for regulatory success through proactive identification and correction of regulatory processes and core care systems. SNFs can perform a PREP survey to obtain comprehensive baseline findings and discover whether or not the community is in compliance with CMS and state regulations.
The PREP survey was implemented to provide focused training on the survey process and the implementation of actions necessary through the quality assessment and assurance (QAA) process to achieve survey success. The process systematically and objectively prepares centers for surveys and assesses all regulatory areas for subsequent review. Through the review, potential practice or process issues are identified and prioritized for resolution.
During HDG’s PREP survey of the community, the consulting team’s surveyor cited eight areas of concern and recommended several additional corrections to practices and procedures.
Results
The most important part of the PREP survey is what the community’s staff does with the information received from the surveyor. By putting HDG’s recommendations to action, the community was able to come back into regulatory compliance prior to their annual survey in March, 2023, and received only one citation at a D level for scope and severity.
