CLIENT ADVISORY: A New CMS Survey Process is Headed to Your Nursing Facility

The Centers for Medicare & Medicaid Services (CMS) intends to implement a new long-term care survey process on November 28, 2017. This new process is part of a larger regulatory revision to implement parts of the Affordable Care Act (ACA), and Improving Medicare Post-Acute Care Transformation (IMPACT) Act. Implementation of the new survey process also correlates with the implementation of Phase 2 of the new Requirements of Participation.

State survey teams across the country currently employ two different survey processes: The Traditional Survey and the Quality Indicator Survey (QIS). The Virginia Department of Health Office of Licensure and Certification still uses the Traditional Survey. The current surveys identify slightly different quality of care (QOC) and quality of life (QOL) issues. CMS has stated that the goal in creating the new process was to create a single, nationalized survey process that is more efficient and effective.

The QIS process primarily focuses on residents and the resident experience, ensuring that residents are informed, involved, and in control of their care. CMS is still rolling out some elements of the new process, so providers should stay informed of CMS website updates and training opportunities to ensure that they understand how to become and remain compliant with the new requirements. Various components of the QIS process are outlined below.

Offsite Preparation and Facility Entrance

Under the QIS process, a surveyor Team Coordinator (TC) will complete offsite preparation using the automated CASPER3 report to identify patterns of repeat deficiencies, the results of the last Standard survey[1], complaints made since the last survey (including active complaints), facility reported incidents (FRI), and variances/waivers. The TC will then make unit assignments using the floor plan from the prior year and considering the mandatory facility task assignments.

In conducting an Entrance Conference, the TC will ask facility leadership to complete a blank facility matrix[2], and an entrance conference worksheet.[3] The TC will also request the following information from the facility:

  • A census with a list of all residents, specifically identifying new admissions;
  • A list of residents discharged from all Medicare Part A services;
  • The facility’s Quality Assessment and Performance Improvement (QAPI) plan;
  • The facility assessment plan;
  • A list of residents who smoke and their smoking times;
  • The number and location of medical storage rooms and carts;
  • The list of residents for the beneficiary notices review;
  • Meal and medication administration times;
  • Access codes to electronic health records; and
  • Other familiar documents: floor plan, form CMS 671/672, and facility policies and procedures.

CMS has indicated that some of these documents—for example, the facility assessment plan[4]—will not necessarily be subject to thorough review. However, in the event that a concern arises during the survey, surveyors can more readily review the documents if they request them upfront.

Further, CMS will instruct the surveyor assigned to the kitchen observation facility task (see below for details) to conduct a brief kitchen visit upon facility entrance to assess the potential for foodborne illnesses.

Initial Pooling and Sample Selection

Under the QIS process, surveyors will consider the following factors in selecting residents for the initial pool: (1) whether the resident is vulnerable, (2) whether the resident was admitted within the last thirty days, (3) complaints or FRIs, and (4) any other significant concern that does not fall into the standard subgroups. Surveyors will pre-select seventy percent (70%) of the resident sample using Minimum Data Set (MDS) information and select the remaining thirty percent (30%) onsite. Surveyors are encouraged to include about eight residents in this initial pool, but they are required to observe every resident.

As with current surveys, surveyors will screen the initial pool of residents through resident and family interviews as well as observation. Surveyors will also conduct a limited record review, checking for advance directives and confirming or clarifying specific information from their observation and interviews. CMS instructs that this part of the process will take about eight hours and should be completed by the end of day one or at the beginning of day two. In the interest of time, CMS encourages surveyors to focus on observation and interviews, hence the “limited” record review. However, CMS has instructed surveyors to conduct more extensive record reviews for newly admitted residents because their information is not contained in the MDS.

The survey team determines the survey sample at the end of the initial pooling process. Under the new survey, the maximum sample is thirty-five residents. Surveyors have discretion and may replace pre-selected sample residents who have been discharged with onsite residents. Surveyors may also replace pre-selected residents if there is a rationale for doing so.

Additionally, surveyors will select five residents for an Unnecessary Medication Review based on observation, interview, record review, and MDS reporting. These residents may be in addition to the sample.


In the investigation phase, surveyors address all concerns that require further investigation for sampled residents and conduct closed record reviews and facility task assignments.

In conducting a resident investigation, surveyors will complete continuous observation to determine whether residents receive appropriate care and services in accordance with the residents’ care plan. Surveyors will also observe and interview staff to determine whether they are implementing the care plan over time and across various shifts. Surveyors will review the facility assessment plan to ensure that the facility competently determines what resources are needed to care for residents each day and during emergencies. Surveyors will also conduct record reviews to the extent necessary to corroborate their observation and interviews.

Closed Record Reviews

In addition to the resident sample, surveyors will follow the Appendix PP and Critical Element (CE) Pathways for closed record reviews. The surveyors will select residents for review based on the following criteria: one resident for Death Review who was not on hospice and died in the last 90 days; one resident for Hospitalization Review who was discharged and has not returned in the last 90 days; and one resident for Community Discharge Review who was discharged to the community in the last ninety days.

Facility Task Investigations

Surveyors will also conduct facility tasks anytime during the investigation process, guided by CE Pathways for each task. A new feature of the survey process is that it groups these tasks into two categories: (1) tasks that must be investigated (mandatory tasks) and (2) tasks that are investigated only if surveyors identify a concern onsite. There are currently nine mandatory facility tasks:

  • Sufficient/Competent Staffing: This is a new task. Surveyors will conduct this facility task using the revised Facility Task Pathway. Surveyors must investigate this matter on every survey. The new requirements emphasize staff competency—surveyors, therefore, will assess whether staffing issues can be linked to resident complaints, or QOL and QOC concerns.
  • Infection Control: All surveyors will observe for infection control. In addition, the assigned surveyor will complete a review of five residents for Influenza and Pneumococcal vaccinations; the surveyor will also review the infection prevention and control and antibiotic stewardship program. Further, the survey team must select a resident who is on transmission-based precautions for review during the initial pool and sample selection processes.
  • Beneficiary Notifications: CMS created a new CE Pathway for this task. The assigned surveyor will select three residents from the list requested upon entrance of residents discharged from all Medicare Part A services to conduct this review. The new CE pathway includes a worksheet that the facility must complete for the selected residents, which outlines the notices given to the residents.
  • Dining Observation: The assigned surveyor must observe the first full meal using Appendix PP and CE Pathway for dining, covering all dining rooms and trays. The surveyor will observe another meal if any concerns are identified in the initial observation.
  • Medication Storage: The assigned surveyor will review half of the medication storage rooms covering different units (based on information requested upon entrance), and half of the medication carts on units where storage rooms were not observed. The surveyor will expand the review if there are concerns.
  • Medication Administration: The assigned surveyor will observe medications for sampled residents whose medication regimen is subject to review. If this is not possible, the surveyor will observe any resident to whom the nurse is ready to administer medications. If a controlled substance is administered, the surveyor will reconcile the count of the medication and ensure the medications passed are not expired.
  • Kitchen Observation: The assigned surveyor will conduct a full kitchen investigation in addition to the brief observation upon facility entrance. These additional observations will gather information on food preparation, storage, and distribution to assess how facility practices prevent foodborne illness to residents.
  • QAA/QAPI: At this time, CMS has not identified changes to this facility task.
  • Resident Council Meeting: This is a group interview with active members of the Resident Council. The questions are different to those asked under the Traditional Survey and QIS. The interview focuses on specific areas related to the functioning of the Council and a few resident specific areas, such as abuse and sufficient staffing, as well as concerns identified in the survey.

In addition to these mandatory facility tasks, surveyors can investigate concerns identified in the environment. Under the new survey process, however, surveyors will not be required to investigate disaster and emergency preparedness, oxygen storage, or the generators.

Best Practices and Considerations

CMS continues to roll out the new long-term care survey process and relevant survey forms and CE Pathways. The CE Pathways identify care concerns and therefore can provide insight into what the surveyors will assess. Consequently, providers should review CE Pathways to understand how to become and remain compliant with the new requirements. This could help providers avoid or limit citations.

Facilities should also remain informed of CMS website updates and training opportunities that will become available in the coming weeks and months. Please refer to the following resources for additional information:

Ensuring that each nursing facility offers services that meet their residents’ needs and appropriately addresses residents’ and surveyors’ concerns is important for both business survival and avoiding survey and legal liability. Should you or your organization have any questions regarding compliance with the new long term care survey process, please contact Peter Mellette ( or Harrison Gibbs (

This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice.

[1] In Virginia, the last Traditional Survey results will apply.

[2] CMS has updated the facility matrix and will release the new version in the coming weeks. Providers should review it and be prepared to complete it either manually or with their software. The care areas on the matrix are different from what is requested in the Traditional Survey.

[3] CMS has also updated this form.

[4] This is a new requirement, effective November 28, 2017 and to be updated annually. See 42 CFR 483.70(e). It is focused on staffing levels, competencies, population needs, and potential hazards.

Categories: Client Advisory