Getting Survey Ready in the Ever-Evolving Regulatory Landscape

Regulatory Shifts and Frequently Cited F-Tags

As state and federal regulators ramp up survey compliance visits in both skilled nursing facilities (SNFs) and assisted living centers, HDG feels it is important to pause and reflect on the primary areas of regulatory focus that leave providers most at risk for citations and fines and discuss helpful tips that can lead to better survey outcomes.

Because the lion share of regulatory surveys were paused, with exception, during the pandemic, many operators have not experienced the stress test of a full annual survey in some time—and the results are starting to show. So far in 2022, the most frequently cited F-tags in the skilled nursing setting include:

• F0884 – Reporting to National Health Safety Network
• F0880 – Infection Prevention & Control
• F0689 – Free of Accident Hazards/Supervision/Devices
• F0684 – Quality of Care
• F0812 – Food Procurement, Store/Prepare/Serve Sanitary
• F0677 – ADL Care Provided for Dependent Residents
• F0656 – Develop/Implement Comprehensive Care Plan
• F0761 – Label/Store Drugs and Biologicals
• F0686 – Treatment/Svcs to Prevent/Heal Pressure Ulcer
• F0609 – Reporting of Alleged Violations

SNFs and nursing facilities (NFs) are required to be compliant with the requirements in 42 CFR Part 483, Subpart B, to receive payment under the Medicare or Medicaid programs. Being “survey ready” always requires that facilities have a functional Quality Assessment and Assurance (QAA) analyzing facility performance and reporting to the governing body/designated person the implementation of the Quality Assurance and Improvement Plan (QAPI) programs.

Evolving Entrance Conference Worksheet Requirements

Being survey ready at a facility should start prior to the surveyors’ arrival. In November 2020, CMS provided a COVID-19 Focused Infection Control (FIC) Survey Entrance Conference Worksheet, but there were no additional changes to the annual Entrance Conference Worksheet. Furthermore, in June 2021, the Entrance Conference Worksheet updates included changes in the following categories in comparison to the one issued in August 2017:

• Information needed from the facility immediately upon entrance, contains seven (7) items
• Entrance conference, contains seven (7) items
• Information needed from facility within one (1) hour of entrance, requesting 8 items
• Information needed from facility within four (4) hours of entrance, requesting 17 items
• Information needed by the end of the first day of survey, one (1) item requested
• Information needed from facility within 24 hours of entrance, three (3) items requested

The requirements in the Entrance Conference Worksheet are continually changing. As we now know, the most current update to this document occurred in January 2022. Unfortunately, the implementation timeframe varied by state and required multiple iterations:

• Information needed from the facility immediately upon entrance
• A list of residents who are confirmed or suspected cases of COVID-19
• Name of facility staff responsible for Infection Prevention and Control Program
• Name of facility staff responsible for overseeing the COVID-19 vaccination effort
• Entrance conference
• A copy of an updated facility floor plan, if changes have been made, including COVID-19 observation and COVID-19 units #12.
• Information needed from facility within one hour of entrance
• Also include the staff responsible for notifying all residents, representatives, and families of confirmed or suspected COVID-19 cases in the facility.
• Information needed from facility within one (4) hours of entrance
• COVID-19 Immunization Policy & Procedures was added to #31
• Lists of residents and staff and their COVID-19 vaccination status was added as #32

The Entrance Conference Worksheet included changes and addition to the previous 2021 document:

• Information needed from facility within one (1) hour of entrance
• List of staff who have confirmed or suspected cases of COVID-19 over the last 4 weeks.
• Information needed from facility within four (4) hours of entrance
• Numbered list of resident cases of confirmed COVID-19 over the last 4 weeks. Indicate whether any resident cases resulted in hospitalization or death
• COVID-19 Healthcare Staff Vaccination Policies and Procedures
• COVID-19 Staff Vaccination Matrix

The Most Recent Entrance Conference Worksheets

Beginning in December of 2021, the Centers for Medicare & Medicaid Services published a series of updated “Entrance Conference Worksheets” with a list of required documentation and timeframes to prepare facilities before a survey.

In less than a month, CMS’ Guidance for the Interim Final Rule – Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination went through three iterations: QSO-22-07-ALL, QSO-22-09-ALL, and QSO-22-11-ALL. While the 30, 60, and 90-day timelines for compliance with vaccination enforcement (from date of memorandum issuance) and adherence to COVID-19 vaccine dose requirements (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), surveyors were instructed not to undertake these efforts or enforce the interim final rule with comment (IFC) in the following circumstances:

QSO-22-07-ALL: The guidance in this memorandum does not apply to the following states at this time: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, West Virginia and Wyoming. Surveyors in these states should not undertake any efforts to implement or enforce the IFC.

QSO-22-09-ALL: The guidance in this memorandum specifically applies to the following states: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Utah, West Virginia and Wyoming. The guidance in this memorandum does not apply to the following state at this time: Texas. Surveyors in Texas should not undertake any efforts to implement or enforce the IFC. States that are not identified above are expected to continue under the timeframes and parameters identified in the December 28, 2021 memorandum (QSO-22-07-ALL).

QSO-22-11-ALL: The guidance in this memorandum specifically applies to the following state: Texas. States that are not identified above are expected to continue under the timeframes and parameters identified in either the December 28, 2021 or January 14, 2022 memoranda (QSO-22-07-ALL and QSO 22-09-ALL).[1]

Survey Readiness in an Ever-Changing Environment

As surveys trend back to pre-pandemic levels, it is crucial to stay current with the latest regulatory requirements to avoid monetary penalties, denial of payments, and even termination of participation from the Medicare and Medicaid payments.

Strategies for being survey ready includes implementing the process steps needed to be organized and confident with the pre-survey activities. Completing and maintaining requested key worksheets, checklists, and reports in anticipation of survey process eases the process and ensures information is promptly provided to surveyors. As operators and long-term care providers, we must maintain and continuously improve the tools at our disposal in order to achieve regulatory compliance and high-quality care for our residents.

Please see the most recent Entrance Conference Worksheet here.

Contact Us

As a national leader in senior care and living management and consulting services, Health Dimensions Group is uniquely positioned to assist organizations with its skilled nursing facility and senior living regulatory expertise. For more information, please contact us at info@hdgi1.com or 763.537.5700.

Learn more by reading our blog post “Top Tips to Improve SNF Inspection Survey Results.”

Authored by: Kathy Karr, RN, NHA
VP, Consulting Services

 

 

 

 

[1] (Note: Surveyors in a state that is subject to QSO-22-07-ALL should start using this document on 01/27/2022. Surveyors in a state that is subject to QSO-22-09-ALL should continue using the Sept 2021 version until 02/13/2022 and start using this document on 02/14/2022. Surveyors in a state that is subject to QSO-22-11-ALL should continue using the Sept 2021 version until 2/21/20022 and start using this document on 2/22/2022.)