Q:
With most facilities awaiting their annual survey after waiting 15 months to 2 years without one, what are some tips for things to double-check to make sure they are prepared?
A:
Answer: One of the most important things to do is to make sure you have all of the Entrance Information prepared and ready for surveyors when they arrive. The CMS Entrance Information Worksheet was revised in June of this year, and CMS also added an updated COVID-19 Focused Infection Control Entrance Information Worksheet as well, that is used during focused infection control surveys. Another important tip is to use the CMS Critical Element Pathways to review the processes in your facility before surveyors arrive. These will help the facility to identify any areas that may need some “fine tuning” before the annual survey. The COVID-19 Focused Infection Control Critical Element Pathway was also updated in June. Finally, don’t forget about the things that must be done annually that surveyors will review, such as reviewing/updating your Facility Assessment and making sure you have completed the annual notification of the “covered individuals” of the F 608 requirements for reporting reasonable suspicion of crimes in the facility. This would include all employees, and any agent or contractor.
- CMS Entrance Information Checklist: (go to downloads, “Survey Resources” https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes
- CMS COVID-19 Focused Infection Control Entrance Information Checklist – go to downloads, “Survey Resources” at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes
- CMS Critical Element Pathways – go to downloads, “LTC Survey Pathways” at: https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/nursing-homes
Contact Proactive for more information on survey preparedness services including mock surveys.
Blog by Janine Lehman, RN, RAC-CT, CLNC Proactive Medical Review
Click here to learn more about Janine and the rest of the Proactive team.