Update survey revisions

Update survey revisions – changes in the survey process of the Health Care Financing Administration

Beth A. Klitch

Since mid-February, the Health Care Financing Administration (HCFA) has released successive revisions to Appendix P, Survey Protocol for Long Term Care Facilities. The most recent draft release as of press time was dated May 5, with implementation planned for July 1. HCFA has used this draft version to conduct surveyor training and to educate providers about expected changes in the survey process. Let’s take a closer look at some of the key provisions.

Quality Indicators

One of the most significant aspects of change in the new survey process is the incorporation of Quality Indicator (QI) information, primarily in the Offsite Survey Preparation task, the Sample Selection task and the various Investigative Protocols. Let’s review the selected Quality Indicators for various domains, based upon the MDS 2.0, that surveyors will use in evaluating quality of care.


1. Incidence of new fractures 2. Prevalence of fails

Behavior/Emotional Patterns

3. Prevalence of behavioral symptoms affecting others

High-risk Low-risk

4. Prevalence of symptoms of depression

5. Prevalence of symptoms of depression without antidepressant therapy

Clinical Management

6. Use of 9 or more different medications

Cognitive Patterns

7. Incidence of cognitive impairment


8. Prevalence of bladder or bowel incontinence

High-risk Low-risk

9. Prevalence of occasional or frequent bladder or bowel incontinence without a toileting plan

10. Prevalence of indwelling catheter

11. Prevalence of fecal impaction Infection Control

12. Prevalence of urinary tract infection


13. Prevalence of weight loss 14. Prevalence of tube feeding 15. Prevalence of dehydration

Physical Functioning

16. Prevalence or bedfast residents 17. Incidence of decline in late-loss ADLs 18. Incidence of decline in ROM

Psychotropic Drug Use

19. Prevalence of antipsychotic use in the absence of psychotic or related conditions

High-risk Low-risk

20. Prevalence of antianxiety/hypnotic use

21. Prevalence of hypnotic use more than two times in the last week

Quality of Life

22. Prevalence of daily physical restraints 23. Prevalence of little or no activity

Skin Care

24. Prevalence of stage 1-4 pressure ulcers

High-risk Low-risk

Three of the above QIs are indicated in bold type to indicate that they are considered “sentinel health events” QIs. This means that the QI represents a significant occurrence that surveyors will select as a concern “even if it applies to only one or a few residents.” The presence of a sentinel health event QI means that the resident(s) with the problem(s) will definitely be included in the sample selection for the survey. In addition, surveyors will focus on flagged QIs, i.e., the facility percentage of occurrence is at or above the 90th percentile, and might focus on unflagged QIs, i.e., the facility is at or above the 75th percentile. The key to understanding your facility’s QI percentiles is that the higher your numbers, the more likely that surveyors will target those items for closer review.

Three QI reports serve as Sources of information for surveyors during the offsite survey team meeting. All of these are now in final form. The first report, “Facility Characteristics,” lists demographic information about the resident population (in percentages) for a single facility compared to all other facilities in the state. The second report, “Facility Quality Indicator Profile,” details a single facility’s performance for each of the Domains and QIs compared to all other facilities in the state. This report also indicates whether the facility “flags” any individual QIs at or above the 90th percentile. The third report, “Resident Level Summary,” provides resident-specific information, including MDS dates and types of assessments, the applicable QIs for each resident, and the total number of QIs flagged for each resident.

Investigative Protocols

HCFA has added some new investigative protocols, and has indicated its intent to develop and integrate yet more investigative protocols into future versions of the survey process. Let’s review a list of the newly proposed investigative protocols, which were subject to revision at press time, but with no major changes anticipated for their final release this summer.

Adverse Drug Reactions (ADR)

The survey team will determine if the resident is experiencing any ADRs as a result of receiving one or more of the medications identified as having high potential for moderate-to-severe ADRs. The survey team will also determine whether the facility’s drug regimen review process identified and reported any potential irregularities associated with the use of such medications and whether there was any response to this notification. (This protocol is used for residents who are over 65 years old, have resided in the facility for more than seven days, and are receiving any of the medications with a high potential for ADRs.)

Pressure Sore/Ulcer

The survey team will determine if the identified pressure sore/ulcer was avoidable or unavoidable, and will determine the adequacy of the facility’s pressure sore/ulcer treatment and prevention. The survey team will observe care delivery to determine if the interventions identified in the care plan have been implemented. (This protocol will be used for a sampled resident with a pressure sore/ulcer from either the high- or low-risk group.)


The survey team will determine if the facility has identified risk factors that lead to dehydration and developed an appropriate preventive care plan, including providing the resident with sufficient fluid intake to maintain proper hydration and health. The survey team is instructed to interview staff, review use of RAPs, identify risk factors leading to dehydration, evaluate the care plan and observe care delivery. (This protocol will be used for a sampled resident flagged for the sentinel even t of dehydration on the Resident Level Summary; a sampled resident who has one or more QIs, such as fecal impaction, urinary tract infections, weight loss, tube feeding or decline in ADLs; and a sampled resident with any risk factors, including vomiting, diarrhea and elevated temperature.)

Unintended Weight Loss

The survey team will determine if the identified weight loss was avoidable or unavoidable and the adequacy of the facility’s response. The survey team will utilize the same follow-up procedures as noted in both of the preceding protocols. (This protocol will be used for a sampled resident with unintended weight loss.)

Dining and Food Service

The survey team will determine if each resident is provided with nourishing, palatable, attractive meals that meet the resident’s daily nutritional and special dietary needs, if each resident is provided services to maintain or improve eating skills, and if the dining experience enhances the resident’s quality of life and is supportive of the resident’s needs, including food service and staff support during dining. (This protocol will be used for all sampled residents identified with malnutrition, unintended weight loss, mechanically altered diet, pressure sores/ulcers and hydration concerns.)

Nursing Services, Sufficient Staffing

The survey team will determine if the facility has sufficient nursing staff available to meet the residents’ needs, as well as licensed registered nurses and licensed nursing staff available to provide and monitor the delivery of resident care. (This protocol is required to be completed for an extended survey, and could be triggered during a standard survey by identification of care concerns/problems associated with sufficiency of nursing staff.)

Abuse Prohibition

The survey team will determine if the facility has developed and operationalized policies and procedures that prohibit abuse, neglect, involuntary seclusion and misappropriation of property. (This protocol will be used on every standard survey and every complaint investigation in which violations of abuse are substantiated.)

I encourage every facility to incorporate use of these same Quality Indicators and Investigative Protocols into an aggressive quality assessment and assurance process immediately, if it hadn’t done so already by July 1. Order (and read) a copy of the May 5, 1999 draft if the final guidelines are not available; have all department directors and key staff attend informational seminars; redesign critical facility procedures to be compliant with the revised survey guidelines; arrange for or conduct a detailed mock survey; provide inservice training to all facility staff; download your facility’s Quality Indicator reports as soon as they become available; and practice measuring your facility’s program of care against the new evaluation techniques. With advance knowledge, improvement of critical care systems, and plenty of practice, your facility can be successful at delivering high-quality care under the revised survey process.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, Ohio. For further information, phone (614)488-1280, write c/o Nursing Homes/Long Term Care Management or fax (216)522-9707.

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