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Make Sure Adequate Documentation On Hand When Preparing for Nursing Home Survey

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

When preparing for your in-person survey, having adequate documentation on hand is key. The documents are essential to ensure that the care you have provided and the resident’s response to that care are accurately reflected. Documents also reduces the risk for liability, informs ongoing care and supports the best outcomes.

Tips for Getting Documents in Order

  • Have reports built and ready to present to the surveyor. If needed, practice running reports and filtering for timeframes.
  • Make sure the admissions packet is updated with all appropriate documents.
  • Be sure to complete all assessments to tell the full story of a resident, as these may capture issues that occurred before admission. For example, a lack of adequate admission assessments can result in facilities behind held responsible for pressure injuries that likely came from a hospital.
  • Make sure care plans and processes are resident-centered, rather than generic.
  • Use the Nursing Documentation Review Checklist during peer review of clinical documentation to assess the completeness and quality of the information included in the notes. You can also use this checklist to build competency with documentation.

Updating the Matrix

It is important to update the Matrix during every standup.

According to one surveyor:

  • It's important to turn in the Matrix in a timely manner. “We need the Matrix for new admissions to complete our screen and choose our initial pool residents.”
  • Don’t be afraid to turn in more than one Matrix. One may be turned in for new admits, and one later that includes all residents.
  • “We can accept reports from the electronic health record, but they must be checked for accuracy.”

To access the Matrix document and all other survey documents:

  1. Go to https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.
  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 “CMS-802.”

Previous Survey Readiness Topics

Getting Focused – Team and Tools

Get Organized

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