Ensuring Survey Readiness for Your Senior Living Facility

Compliance and risk management are critical components of running a senior living facility. Our recent webinar, "Survey Process and Management," provided in-depth insights into how facilities can better prepare for regulatory surveys, maintain high-quality care standards, and manage risks associated with non-compliance.

Why Survey Readiness Matters

More than just meeting state and federal requirements, regulatory compliance directly impacts your five-star quality rating, which influences insurance contracts, referrals, and financial health. A poor survey can lead to:

• Increased insurance premiums and potential loss of coverage.
• Civil monetary penalties and other regulatory remedies.
• Reputational damage, affecting census levels and business development.

Facilities can protect resident rights, ensure quality care, and maintain financial stability by proactively managing survey readiness.

Understanding the Five-Star Quality Rating System

The Centers for Medicare & Medicaid Services (CMS) calculates a facility's star rating based on:

• Health Inspections (50% weight): Scores from the last three annual surveys and complaint investigations.
• Staffing Levels (33% weight): Nurse and care staff hours per resident.
• Quality Measures (16% weight): Performance indicators such as falls, pressure ulcers, and medication use.

A strong survey outcome starts with maintaining compliance across these areas. However, since only 10% of facilities nationwide can be five-star rated at any given time, continuously improving internal processes is essential.

Key Steps to Survey Readiness

Using a seven-step survey process, facilities can prepare at every stage:

• Offsite Preparation: Surveyors review past citations, incident reports, and Payroll Based Journal (PBJ) staffing data before arriving.
• Facility Entrance: Administrators must provide key documentation (e.g., policies, logs, agreements) immediately.
• Initial Resident Pool Review: Surveyors conduct resident interviews, observations, and record reviews.
• Sample Selection: Identifying high-risk areas that require further investigation.
• Investigations: Surveyors use Critical Element Pathways to assess compliance in clinical and operational areas.
• Additional Activities: Review of infection control, staffing, medication administration, and kitchen sanitation.
• Exit and Deficiencies: Facilities receive a 2567 report and must submit a Plan of Correction (POC) within 10 days.

Survey Readiness by Department

Survey preparedness is a team effort, and every department plays a role in maintaining compliance, including:

• Administration: Maintain updated facility assessments, QAPI plans, and grievance logs.
• Nursing & Clinical Teams: Ensure accurate documentation, resident assessments, and infection control protocols.
• Business Office: Provide trust fund accounting, transfer notices, and beneficiary notifications.
• Housekeeping & Maintenance: Keep sanitation logs, emergency preparedness plans, and equipment maintenance records up to date.
• Social Services: Maintain resident rights documentation, discharge planning records, and trauma-informed care plans.
• Dietary Services: Adhere to food storage, menu substitutions, and meal service protocols.

Actionable Tips to Avoid Citations

To minimize survey risk:

• Conduct routine internal audits using CMS Critical Element Pathways.
• Ensure policies are updated and accessible to staff.
• Train staff on documentation best practices (e.g., accurate MAR/TAR sign-offs).
• Proactively address past citations before surveyors arrive.
• Implement a tracking system for compliance areas like wound care, falls, and medication reviews.

Looking Ahead: 2025 Survey Changes

Starting in February 2025, CMS implemented new survey protocols, PBJ updates, and QAPI modifications. review QSO Memo 25-12-NH, which outlines these updates in detail.