Survey Survival

SURVEY survival

Are you aware of these new survey requirements?

In the past few months we have encountered much “to do” regarding the changes in F-tag 314 Pressure Ulcers; however, little has been said regarding the State Operations Manual (SOM) Appendix PP-Guidance to Surveyors for Long Term Care Facilities, Revision 5, which was issued, became effective, and was implemented on November 19, 2004. One might think that this is because there wasn’t much in it that was new, but such thinking is wrong. Not only was a tremendous amount changed, but serious ramifications await those facilities that do not review their own operational policies and procedures and take steps to update them to meet the new manual’s expectations. My goal in this article is to give you the framework to be successful in meeting these new expectations.

What to Do First?
Because the new update involves all departments, you and your department directors must have a copy of the new SOM, and each nursing unit and supervisor should have a copy available for reference. Also, add a copy of the revised manual to the facility’s library or survey binder to provide resident access to the changes, as required under revised resident rights in the new SOM.

It never ceases to amaze me just how far behind facilities can be in obtaining current, necessary information on operating under government regulation. As late as four months after its release, I was still coming across facilities that not only did not have this new version, but had key department staff who hadn’t heard about the update. If you have not already downloaded your copy of the new SOM, visit

What Are the New Expectations?
Let’s look at what revisions were made and how they may change the way you do things in your facility. An index for easy reference (but lacking mention of 493.25[d], the tags addressing bladder care and catheterization that are still under review [see my article “Preparing for CMS’s Continence Care Revisions,” ]) is included. Below are basic descriptions of the pertinent revisions and suggestions on possible operational adjustments needed.

Resident Rights 483.10(d)(2) F154.
Revision. Providers will need to show that a resident was informed in advance about care and treatment and of any changes in that care that may affect the resident’s well-being. Interpretive guidelines have been added regarding the definition of what “informed in advance” means.

Tip. The facility should review and revise its policies and procedures on resident information, as needed, and provide staff education relative to these. Documentation should minimally cover points found within the interpretive guidelines. Also, be aware that the guidelines’ revisions do not address what to do in cases in which the resident cannot comprehend the meaning of the care and treatment information. In long-term care, a general standard of practice is that the resident’s responsible party/legal guardian be informed on the resident’s behalf. Needless to say, the resident’s or responsible party’s feedback on the advanced care and treatment notice, carefully documented, will play an important part in determining facilities’ compliance.

Notice of Rights and Services 483.10 (b)(1) F156.
Revision. It is stated clearly that residents are to be made aware of their legal rights and responsibilities and that the facility communicate these rights and responsibilities upon admission and at any time changes occur, in writing and in a language the resident can understand.

Tip. Resident rights materials can be purchased in alternate languages from a variety of resources or obtained free or for a minimal charge from your local state ombudsman. However, facility-specific policies or practices on residents’ rights cannot, and providers must devise their own. Now is the time to adopt or update your resident handbooks in the languages that residents commonly speak in your facility. You may have to hire a translator (possibly a good community service project for your local college or high school, provided their work is reviewed by a credible resource). Abuse policies need to be updated regarding noncompliance with the advance directives requirements found in 483.10(b)(7) of this tag. Reviewing changes in abuse policies during a resident and/or family council meeting and having the minutes reflect this communication provides an additional opportunity. The facility’s newsletter is also an avenue of positive marketing communication; take advantage of it. Regardless of the method of communication, make sure that resident rights and responsibilities and any changes made to them are governed by policies and procedures that staff understand and adhere to.

Privacy and Confidentiality 483.10(e) F164.
Revision. Storing, securing, and keeping confidential resident information in residents’ records is the essence of the revision. The record should show the location of this confidential information (if not in the chart). It is not uncommon that social services keep confidential resident records in a location separate from the medical record, for example, but facility policy should govern this practice.

Tip. Review and revision of the facility’s medical record confidentiality policy and procedures should be completed.

Accommodation of Needs 483.15(e) F246.
Revision. The first revisions with possible “substandard care” ramifications relate to space accommodations and equipment. This regulation means to ensure that dining, health services, recreation, activities, and programs’ areas are functional and are large enough to comfortably accommodate the needs of the residents who usually occupy these spaces. This applies to adequate storage space for resident property, activities materials, therapy equipment (to maintain it in good condition), and other items requiring safe and proper storage.

Tip. You will need to take a close look at resident common and private areas, equipment, and supplies of all departments. Heavy emphasis is on activity and dining areas, resident furnishings, and their appropriate use and functionality given the space available. For example, delayed meals because activities materials have not been removed from the dining room, or therapy provided in hallways rather than therapy rooms, can be problems.

Personal Property 483.10(l) F252.
Revision. This quality-of-life regulation aims to encourage residents to bring personal possessions into the facility, as permitted by space, safety considerations, and the fire code, and to ensure that this personal property is treated with respect for what it is and may represent to the resident.

Tip. This is another area that can be addressed in a resident handbook and provided easily to residents and families upon admission. Include a statement that the facility has the right to limit the resident’s exercise of this right on grounds of space, health, or safety. Outline the expectations the facility places on the resident regarding compliance along these lines. Meanwhile, develop procedures that will assist your facility in determining safe use of personal possessions-for example, electric wheelchairs, scooters, and lift chairs. You may have a resident periodically demonstrate his or her appropriate use and skills in safely operating these devices.

Resident Assessment 483.20 F272.
Revision. The previous language is still present, but additional intent emphasizes the need to conduct resident observation and communication as part of the data-gathering process.

Tip. Policies and procedures should have resident observation and communication added to the data-gathering process, if it’s not there already. For compliance purposes, staff should document resident observations and communication in a narrative format. Also, in the Resident Assessment Protocol (RAP) Summary documentation, indicate relevant facts provided by those staff and family members who participated in the assessment review. You also may have them sign the RAP, in addition to signing it yourself.

Comprehensive Care Plans 483.20(d) F279.
Revision. A facility must use the assessment’s results to develop, review, and revise the resident’s comprehensive plan of care.

Tip. This is a small addition that has a mighty outcome. This will cause many interdisciplinary teams (IDTs) to change the way business is conducted. It means, at the very least, that the final assessment results must be reviewed by Quality Assurance to ensure that a comprehensive plan of care based on the assessment is developed and implemented. The development of care plans must be attributable directly to the final findings of the assessment.

It is recommended that the IDT (understood to include representatives from each clinical department) review the final MDS together and develop a problems, issues, needs, or concerns list, and then develop the care plan from this list. As always, those items that do not trigger a RAP, such as assessed pain, special care and treatment needs, and nursing rehabilitation and restorative care, should be included in the comprehensive plan of care.

Comprehensive Care Plans 483.10(d) (3)F280.
Revision. The focus is on affording residents and responsible parties the opportunity to participate in the care planning process. If they are not included, the facility is expected to offer a legitimate reason for this (e.g., the resident was adjudicated incompetent or incapacitated under state law).

Tip. A policy and procedure revision may be necessary that includes the mandate that all residents are provided with notice of care plan meetings, time, and date, and allowed participation in the care plan process. Attach to the policy a copy of the forms to be used. Form letters and mailing practices should be outlined clearly for invited participants other than the residents themselves. For instance, return receipt request is a good idea for those who have state guardianship and other legal oversight.

Providing assistance to and from the care plan meeting and having the IDT go to the resident’s room to review the plan of care are practice options to ensure the resident is present. Obtaining the resident and/or responsible party’s signature is still paramount to show that they were afforded the opportunity and that the meeting was conducted.

A care plan summary/signature sheet should include a statement that the final care plan was reviewed and that those in attendance were provided the opportunity to ask questions or seek clarifications, and it summarizes all items that were discussed relating to the plan of care. When writing progress notes, staff should include the dates and times of resident observation and interviews that assisted them in developing the plan and whether care options or changes were discussed.

Coordination 483.20(e) F285.
Revision. Two focus points are found here: first, the facility should avoid duplicate testing and treatment efforts through coordinated assessment; and second, the state is responsible for performing the Preadmission Screening and Resident Review (PASRR) process for cases of possible mental illness, including screenings, preparing reports, and providing or arranging for any specialized services that might be needed. The state also is required to provide the facility with a report.

Tip. Review and revision of admission policy relating to the PASRR process is the first step; the second is to copy this updated policy and procedure to your state office. In a cover letter, copy them the revised F285 language.

Medication Errors 483.25(m) F332 & 333.
Revision. This simply incorporated one set of guidelines into both tags.

Standard Menus and Nutritional Adequacy 483.35(c) F363.
Revision. Changed from F563 to F363.

Physician Visits 483.40(b) F386.
Revision. Changes were made in physician signature requirements under item (3) sign and date. All orders, with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications, are required to be signed by a physician.

Tip. Your medical director should review physician signature policies. A good idea is to distribute a PDF copy of the new SOM to all the facility’s attending physicians.

Life Safety From Fire 483.70(a).
Revision. This included adoption of the National Fire Protection Association’s NFPA 101« 2000 edition of the Life Safety Code«, issued January 14, 2000. It is indicated that facilities have until March 2006 to be in compliance (an exception being Chapter, exception number 2; check the SOM).

Also, be advised that on March 25, 2005, the Federal Register was updated to include the requirement for nursing homes that do not have sprinkler systems or hardwired smoke detectors to install battery-operated smoke detectors in patient rooms and public areas. In addition, nursing homes are on the list of healthcare providers allowed to install alcohol-based hand sanitizer dispensers in exit corridors as an encouragement to handwashing, but they must meet guidelines for safe location of these potential accelerants.

Tip. Get a copy of NFPA’s Life Safety Code by writing to the address in the SOM or go to You will notice that they offer a copy on CD, which makes for easy distribution. You’ll want to get a copy to each department director. By addressing the Life Safety Code within the confines of the Quality Assurance program, facilities will be able to show that they are working toward compliance. Minutes should show the items identified and actions to be taken, along with time frames and staff responsibility in this area.

Resident-identifiable information 483.20(f)(5) F516.
Revision. The need to protect and keep unauthorized disclosure of the resident’s information from occurring is the focal point of these revisions.

Tip. If you have not already done so, you’ll want to obtain provider agreements/contracts of agents working in your facility who need access to resident records. Many have current policy and procedures because of HIPAA implementation.

For questions and concerns regarding CMS revisions, contact Karen Schoeneman at (410) 786-6855 or
Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky. For more information, call (877) 987-2001.
To send comments to the author and editors, please e-mail To order reprints in quantities of 100 or more, call (866) 377-6454.

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