Still Waiting for Your Nursing Home Survey?

The Department of Health (DOH) has resumed recertification surveys, but many nursing homes still have not been surveyed. For some, it has been over two years since their last survey. The retirements of some survey staff, the onboarding of new staff, and delays related to education around the new Centers for Medicare and Medicaid Services (CMS) guidance issued in October 2022 have all contributed to the delay. Just as an example, looking at September 2019, pre-pandemic, 43 surveys were completed. In 2020, at the height of the pandemic, recertification surveys were halted. In 2021, when surveys resumed, 31 surveys were completed in the month of September. However, in 2022, the number of surveys for September actually dropped to 24. Other months showed similar patterns of decreased surveys from 2021.

Nevertheless, surveys are being conducted, and deficiencies are being cited. The top regional deficiencies as well as the top statewide deficiencies are available here. As has been the pattern, there are regional differences in focus, and members would be wise to become familiar with what citations are being identified on a regional basis. While the top most cited deficiency may differ from one region to another, many of the most cited deficiencies are similar from region to region. Care Planning (F656); Storage, Preparation, and Serving of Food in Accordance with Professional Standards (F812); and Accidents (F812) were cited in most of the regions.

For those members still awaiting survey, there are steps that they should consider to potentially improve results. Review last survey's citations, and determine if the correction of those deficiencies has been maintained. Conduct environmental rounds to identify infection control issues and situations that might contribute to a potential accident. Review the facility's Quality Measures to identify areas of concern or unfavorable trends. Monitor Resident Council minutes and Grievance logs to identify and correct areas of dissatisfaction, especially ones that may have been raised on an ongoing basis. Some issues identified may not be able to be resolved, but there should be documentation that they were at least investigated and responded to.

In addition, members should consider available LeadingAge NY resources. For issues related to Five-Star, especially guidance related to interpreting and improving Quality Measures, members should contact Sue Chenail at schenail@leadingageny.org.

Members interested in a mock survey from LeadingAge NY ProCare should contact Elliott Frost at efrost@leadingageny.org. ProCare consultants utilize the DOH survey process and in addition provide complete written findings as well as specific recommendations at the exit conference to address identified non-compliant issues.

Contact: Elliott Frost, efrost@leadingageny.org, 518-441-8761