Skilled Nursing Facility Surveys

In order to receive payments and remain certified under the Medicare and Medicaid programs all skilled nursing facilities (SNF’s) are required to undergo an annual health inspection in the form of an unannounced standard survey by a professional surveyor. The purpose of the standard survey is to ensure SNF’s are in compliance with relevant healthcare rules and regulations.

Prior to 2017 there were two types of standard surveys—the traditional survey and the quality indicator survey (QIS). The traditional survey was conducted on paper and computers were only used at the end of the survey to input areas of noncompliance. The QIS is a more modern computer-based survey which the Centers for Medicare & Medicaid Services (CMS) created in order to improve the quality and consistency of SNF surveys. The QIS is a two-stage process in which surveyors first systematically review specific nursing home requirements and then investigate issues that arise.


In 2017, CMS created a single type of computer-based standard survey which combines the traditional survey and the QIS. The purpose of the new survey is to create a national standard which builds on the strengths of the two survey types and incorporates effective, innovative, and modern approaches to SNF surveying. The new survey contains three stages: an initial pooling process, a sample selection process, and an investigation.

Before each standard survey begins the surveyor will conduct preparatory work off-site during which he/she will access data about the SNF and independently reviewing the SNF’s history. After completing this preparatory work the first stage—the initial pooling process—will begin. During this stage surveyors will conduct an initial review of around eight SNF residents, a process which includes interviews of residents and their family members, observations, and a medical record review.


The second stage is a sample selection process where the survey team will conduct a meeting to review and analyze data collected during the first pooling stage and choose a sample portion of the data that will be used in the final investigation phase. The number of residents selected during this process must consist of approximately 20% of the SNF’s census. In addition, during this sample selection stage the survey team will choose a sample of discharged residents which will be used for a closed medical record review that will also take place during the final investigative stage.


The final stage of the survey is an investigative process whereby additional observations and reviews are conducted with a focus on investigating any areas of concern that were identified during the previous two stages. During this investigative stage the survey team must conduct nine “mandatory tasks” as well as closed record reviews of the discharged residents selected during the sample selection phase.


After finishing all three stages there is an exit conference in which the surveyor informs the SNF administrator of the preliminary survey findings, including potential areas of noncompliance, and gives the administrator a chance to ask questions or provide additional information.


If the surveyor finds an area of noncompliance during the survey he/she will classify the violation according to a federal “F-Tag” numbering system, so-called because SNF regulations are set forth in subsection F of the federal regulations governing SNF’s. Each F-Tag corresponds to a particular long-term care facility regulation.


An instance of noncompliance is also known as a “deficiency,” and for each deficiency discovered the surveyor must assign it an alphabetical letter based on how serious it is. In doing so, the surveyor will first determine the level of harm caused by the deficiency to the SNF resident(s). This determination is referred to as the “severity” of the deficiency. Then, the surveyor will determine the scope of the deficiency. Finally, based on the severity and scope of the deficiency the surveyor will assign it an alphabetical letter on a scale of A through L, with “A” being the least serious and “L” being the most serious.


If the surveyor finds an incidence of noncompliance during the survey he/she may conduct a revisit survey, which is designed to reevaluate the specific care and services that were cited as noncompliant during the standard survey. However, revisit surveys are not required for most deficiencies classified below the letter F.


If during the course of a standard or revisit survey the surveyor finds that a particular SNF’s noncompliance is so severe that it constitutes what’s known as “substandard quality of care” (SQC), then the surveyor will inform the SNF administrator that an extended (or partial extended) survey must be conducted. An SQC exists if the surveyor finds one or more deficiencies which “constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm.”

Finally, surveyors may also conduct ad hoc complaint surveys, which are surveys carried out in response to specific complaints made about an SNF. 

The fallout from noncompliance can be disastrous for SNF’s because it can result in severe financial penalties. The importance of healthcare compliance can’t be understated, and that’s why we here at Clearpol created Policies.ai software. It’s designed to help SNF’s stay on top of the myriad healthcare rules and regulations and create internal policies and procedures to ensure compliance with federal, state, and local laws.

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