Regulatory Update

13 Questions to Prepare for on State Surveys

Polaris Group Profile
Polaris Group
September 28, 2022
March 14, 2023
Polaris Group Profile
Polaris Group
March 14, 2023
Summary

Prepare for upcoming October changes to the nursing home surveyor process by reviewing these 13 key questions.

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CMS recently released copies of the updated Long-Term Care Survey Process (LTCSP) Critical Element Pathways and will begin using these new tools in October 2022.

FTag 880 – Infection Prevention and Control- has risen to center stage and is currently the most commonly cited FTag nationwide.  This FTag has resulted in more deficiencies, including substantial civil money penalties, than any other Tag.

Prior to 2020 and for over a decade, F812- Food Preparation/Storage/Services/Procurement was the most commonly cited tag. So, what are the important points that all employees need to know?

13 questions to help prepare for state surveyors

Based on the recent updates to the critical element pathways, nursing home facilities should prepare for increased surveyor scrutiny in infection prevention and control. Surveys will focus on three key areas: infection control, cleaning, and screening.

Here’s what surveyors are watching for and asking about during the survey visit.

  1. Are team members covering their cough appropriately?
  2. Are all facility areas cleaned with disinfectant?
  3. Is all reusable resident medical equipment cleaned between uses according to manufacturer’s instructions?
  4. Do all team members wash hands and/or use hand sanitizer between tasks?
  5. Are residents offered to wash their hands after toileting and before meals?
  6. How are residents reminded to perform hand hygiene?
  7. Are necessary supplies readily available, and if not, do employees know who to contact for replacement supplies?
  8. Is PPE worn according to CDC guidelines, changed appropriately, and discarded properly?
  9. Do team members know how and when to put on and take off isolation gowns, masks, and face shields?
  10. Do team members know the different types of isolation status and what impact isolation has on direct care?
  11. Is proper signage posted for when visitors should not enter the nursing facility?
  12. What type of screening is performed upon entry to the facility?
  13. Does the facility store, handle, transport, and process linens properly?

With high rates of staff turnover, it can be extremely challenging to re-educate current employees and constantly be training new staff. However, it is critical that all employees receive training in infection control and have acceptable responses to any surveyor questions. Incorrect responses can trigger further surveyor scrutiny and review.

Other ways to get prepared

Polaris Group has numerous tools to support your facility before your state survey. Scheduling a mock survey with Polaris Group is the most effective way to assess staff preparedness and ensure a deficiency-free survey. Contact Polaris Group to learn about opportunities for staff education and preparation so your facility can meet this increased surveyor scrutiny in infection control.

CMS recently released copies of the updated Long-Term Care Survey Process (LTCSP) Critical Element Pathways and will begin using these new tools in October 2022.

FTag 880 – Infection Prevention and Control- has risen to center stage and is currently the most commonly cited FTag nationwide.  This FTag has resulted in more deficiencies, including substantial civil money penalties, than any other Tag.

Prior to 2020 and for over a decade, F812- Food Preparation/Storage/Services/Procurement was the most commonly cited tag. So, what are the important points that all employees need to know?

13 questions to help prepare for state surveyors

Based on the recent updates to the critical element pathways, nursing home facilities should prepare for increased surveyor scrutiny in infection prevention and control. Surveys will focus on three key areas: infection control, cleaning, and screening.

Here’s what surveyors are watching for and asking about during the survey visit.

  1. Are team members covering their cough appropriately?
  2. Are all facility areas cleaned with disinfectant?
  3. Is all reusable resident medical equipment cleaned between uses according to manufacturer’s instructions?
  4. Do all team members wash hands and/or use hand sanitizer between tasks?
  5. Are residents offered to wash their hands after toileting and before meals?
  6. How are residents reminded to perform hand hygiene?
  7. Are necessary supplies readily available, and if not, do employees know who to contact for replacement supplies?
  8. Is PPE worn according to CDC guidelines, changed appropriately, and discarded properly?
  9. Do team members know how and when to put on and take off isolation gowns, masks, and face shields?
  10. Do team members know the different types of isolation status and what impact isolation has on direct care?
  11. Is proper signage posted for when visitors should not enter the nursing facility?
  12. What type of screening is performed upon entry to the facility?
  13. Does the facility store, handle, transport, and process linens properly?

With high rates of staff turnover, it can be extremely challenging to re-educate current employees and constantly be training new staff. However, it is critical that all employees receive training in infection control and have acceptable responses to any surveyor questions. Incorrect responses can trigger further surveyor scrutiny and review.

Other ways to get prepared

Polaris Group has numerous tools to support your facility before your state survey. Scheduling a mock survey with Polaris Group is the most effective way to assess staff preparedness and ensure a deficiency-free survey. Contact Polaris Group to learn about opportunities for staff education and preparation so your facility can meet this increased surveyor scrutiny in infection control.

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