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Getting Organized Key to Improving Nursing Home Survey Outcome

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

When it comes to in-person nursing home surveys, being organized can reduce stress, improve your survey outcome and lessen the amount of time a surveyor is in the building.

Ways to Get — and Stay — Organized

  • Make a survey book — a binder with tabs that reflect the Entrance Conference Worksheet and sections that incorporate what is in each Pathway document. Update the survey book regularly, e.g., daily for census and as needed when there are leadership changes. Facilities that prepare a survey book and keep it updated impact how quickly the team completes the survey process.

    To access the LTC Survey Pathways documents:
    1. 1. Go to https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.
    2. 2. Scroll down to "Downloads" and select Survey Resources with Staff Vaccine Documents to download the ZIP file.
    3. 3. Open the downloaded ZIP file and then open the LTC Survey Pathways folder (within the ZIP file) to access PDF and Word versions of the documents.
  • Create a 12-month calendar that captures the areas to review each month.
    • List each month’s areas to review in order of importance from most to least important.
    • Start with the critical element pathways. Our Survey Readiness Elements Tracking Tool and Calendar can assist in identifying and tracking monthly activities.
    • Indicate when to review each section, e.g., annually, monthly, etc.
  • Update the Facility Assessment and the Emergency Preparedness Plan annually. The Facility Assessment Tool and Long-Term Care Requirements: CMS Emergency Preparedness Final Rule can help you with this process. Consider tracking these updates in the 12-month calendar.
  • Establish a protocol for staff to follow if the administrator and DNS are unavailable when the survey team enters the facility during regular hours, after hours and on weekends.
  • Make sure staff are consistent with processes no matter which staff member is conducting the process. Create a quick reference sheet for where to find everything.

Previous Survey Readiness Topics

Getting Focused – Team and Tools

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