New Year’s Resolution for Your LTC Facility: Prep for CMS Survey Process

Tip: The best way to prepare is to create a survey-ready culture

The Centers for Medicare & Medicaid Services (CMS) expects your long-term care facility (LTCs) to uphold certain requirements for Medicare participation—and conducts surveys to see that you are. Though the Phase 2 of CMS’s regulatory program took effect back in November 2017, it introduced an evaluation survey that some facilities still struggle to understand.

If you’re one of these facilities, take heart—and take a listen to the AudioEducator webinar “Know the New CMS Survey Process in 2019” presented by healthcare compliance educator Carmen Bowman. During her talk, Bowman explains how to create a survey-ready culture that can withstand even the toughest of scrutiny.

Phase 2: A Push for Patient-Centered Care

Let’s recap the LTC requirements for program participation—and what’s changed.

Although this newest program was introduced in November 2016, Medicare and Medicaid requirements LTC facilities’ participation have been around for a while. Originally published in February 1989, no new revisions to these requirements were made until the November 28, 2016 Final Rule. Phase 1 of the program lasted until November 28, 2017, when the current Phase 2 began. LTCs must abide by Phase 2 rules until Phase 3 begins at the end of this year: on November 28, 2019.

Prior to Phase 2, CMS had two surveys: Quality Indicator Survey (QIS) and Traditional. When designing this second phase, CMS sought to improve the effectiveness and efficiency of the CMS survey process, which meant taking the best out of both surveys and combining elements to create one nationwide process. A main goal of this new single CMS survey process is that it be resident-centered while also advancing patient care innovation.

4 Areas of Focus in Survey Preparations

The current CMS survey process, for which you’ll want to be prepped and ready, consists of 3 parts:

  • Initial pool process (sample size is based on census)
  • Sample selection of residents, done between the end of first day and beginning of second
  • Investigation of the facility

The main foci of Phase 2 investigations are:

  • Quality Assurance and Performance Improvements (QAPI)
  • infection prevention and control
  • antibiotic stewardship
  • vaccination and medication control

Take note: As a result of the above criteria, surveyors will focus on the following in their investigations—areas you should give special attention to when preparing:

  • Abnormalities in the dining process (this will include a full kitchen inspection)
  • Distribution of unnecessary medications
  • Abuse of antibiotics
  • Missing flu and pneumococcal vaccinations.

Combat Survey Stress with a Survey-Ready Culture

With all the administrative work that goes into running your facility, you want to add as little burden as possible, so the best way to prepare for a survey is to create a survey-ready culture within your facility. If survey-readiness is in your DNA, then you’ll never be caught off guard.

Here are some ways you can implement this ever-ready culture in your facility:

  • Check requirements for the Antibiotic Stewardship Program and address any areas in which your facility is not currently compliant.
  • Create a plan for survey readiness and implementation of any new protocols.
  • Pinpoint training needs and develop a budget for this training accordingly.
  • Identify points of communication for during a survey.
  • Implement training for staff on a regular basis

Keep Patients the Top Priority

If you lack confidence in your facility’s ability to measure up, now is the time to take action—and extra preparatory steps—before surveyors come knocking! After all, you and CMS want the same thing: the best care for your patients, notes Bowman. In her webinar, “Know the New CMS Survey Process in 2019,” she acquaints you with the new survey process, survey resources, and tips to manage the survey, thereby making you stronger in your daily work.

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