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Areas Related to Staffing Important Part of Nursing Home Surveys

In-person surveys for nursing home facilities have restarted for the first time since the COVID-19 pandemic began in 2020. In this fourth installment of a seven-part series, get tips on how being organized can help your staff and center be survey ready.

Surveyors focus on multiple areas involving staffing, so it is vital to have proper tracking and documentation. Below is a review of the three staffing-related areas surveyors will focus on during a survey, as well as tips to help you get prepared.

Staff Numbers

A citation is possible if the staff-to-resident ratio is low.

  • Track and document what the facility is doing to hire more staff.
  • If necessary, have management assist with care.

Staff Competencies

Facilities may also be cited on staffing competencies.

  • Use CMS’ Toolkit 1: Staff Competency Assessment to assess staff members’ knowledge and understanding of behavioral, technical and resident-based care.
  • Comagine Health’s Tracking Tool for Staff IPC Trainings can aid you in keeping track of the most recent infection prevention and control trainings staff members have received. It can also help you ensure your facility has met the regulation pertaining to infection control training in the State Operations Manual Appendix PP (Advanced Copy) under citation code F495; §483.95(e) Infection Control.
  • For med pass competencies, pharmacies have the competency sheets.
  • Medication administration can occur as early as one hour before or as late as one hour after the scheduled medication time. Make sure your medication administration policy and procedure includes this information.
  • Randomly quiz staff members to make sure they know how to do procedures and have employees conduct peer-to-peer reviews. See if processes are followed consistently to ensure all staff members are doing things the same way.
  • Conduct mock audits to prepare staff for surveys and ensure everyone is well-versed in how the facility is organized. Retain documentation of these audits for future reference.

Staff Vaccination Tracking & Documentation

  • CMS requires facilities to fill out the Staff Matrix F888 document for staff vaccinations at the time of survey. Update the document whenever there are changes.
  • The Staff Formulas for F888 spreadsheet calculates compliance with the requirement at F888 for COVID vaccinations. This spreadsheet may also be useful as a QA and survey prep tool. Even if you are tracking the same data in a different format, you must complete this spreadsheet for the surveyors.
  • Although rows six and seven are on the spreadsheet, you can ignore them, as we are past the 60-day window for partially vaccinated staff. New hires who have started their vaccination series — but not completed it because not enough time has passed between doses — go under column 10.
  • The calculations surveyors use to determine compliance are in rows 10 and 11. If the box in row 11, column F is 100%, the facility is compliant with staff vaccinations; if it is less than 100%, the facility is considered noncompliant.
  • However, surveyors will cite facilities if their policies do not meet the requirements at F888, which emphasize individualized facility processes for offering vaccinations, education on vaccinations, contingency planning for staff who decline the vaccination (increased PPE requirements, unit assignments, etc.) and the process by which a staff member can apply for a medical or nonmedical exemption to the requirement.
  • Vaccination counts must match what has been reported to the state and NHSN. If the difference between percentage of staff reported to the surveyors is more than 10% +/- from the data on NHSN, you must be able to explain that discrepancy to the surveyors (rows 2 and 3). It doesn’t automatically mean a deficiency — the NHSN data the surveyors look at might be about a week old, the facility may have several new hires, etc. — but the survey process requires the surveyor to document an explanation.

To access the Matrix document and all other survey documents:

  1. Go to
  2. Scroll down to “Downloads” and select Survey Resources with Staff Vaccine Documents to download the ZIP file.
  3. Open the downloaded ZIP file and then open the Survey Resources folder (within the ZIP file). The matrix document is titled “Staff Matrix for F888,” and the Excel document is called “Staff Formulas for F888.”

Other Survey Readiness Topics

Getting Focused – Team and Tools

Get Organized

Have Adequate Documentation

Quality of Care and Data Review

Emergency Preparedness Plan 

Infection Prevention

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