Survey Preparedness

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Skilled nursing centers and nursing facilities are required to follow extensive rules in the Requirements of Participation (ROP) to receive payment under the CMS Medicare or Medicaid programs. These requirements are contained in the Federal Regulations for Nursing Facilities, which also state each center must comply with all applicable Federal, State, and local laws, regulations, and codes with accepted professional standards. The AHCA regulatory team provides members with guidance and resources to help them understand the survey process and implement the requirements.  

Need help locating a specific resource? Download the AHCA Regul​a​tory Resources Guide, which provides direct links to all available tools to help you prepare for surveys.

 SURVEY TIPS to Maintain Compliance

The AHCA regulatory team is developing survey tips to assist in maintaining compliance with skilled nursing regulations, as well as preparing for surveys. The team will review trends for citations and provide tips for staying in compliance with these regulatory areas.​​​

 

 

Survey Tip - Transfer and Dischargehttps://www.ahcancal.org/News-and-Communications/Blog/Pages/Survey-Tip--Transfer-and-Discharge.aspxSurvey Tip - Transfer and Discharge9/4/2024 4:00:00 AM<p>A new survey tip has been posted on the <a href="/Survey-Regulatory-Legal/Pages/default.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">AHCA Survey Regulatory page</a> for your review. In the Survey Tips section, you’ll find insights related to recent survey trends. The latest survey tip focuses on regulations regarding Resident Rights, specifically F550 - Resident Rights. The <a href="/Survey-Regulatory-Legal/MemberOnlyDocs/Survey%20Tips/Survey%20Tip%20for%209.4.24.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">tip sheet</a> provides helpful guidance on this topic. For any questions, please email <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org​</a>. ​</p>A new survey tip has been posted on the AHCA Survey Regulatory page for your review.
Updated CMS MDS Section GG Web-Based Training Series Now Availablehttps://www.ahcancal.org/News-and-Communications/Blog/Pages/Updated-CMS-MDS-Section-GG-Web-Based-Training-Series-Now-Available.aspxUpdated CMS MDS Section GG Web-Based Training Series Now Available8/27/2024 4:00:00 AM<p>​<span style="font-size:11pt;">CMS has released an updated series of web-based training courses that provide an overview of the assessment and Section GG guidance found in the </span><a href="https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" style="font-size:11pt;">Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual</a><span style="font-size:11pt;">, Version 1.19.1. These courses are designed to promote accurate coding of the post-acute care (PAC) cross-setting data elements. </span></p><div><span style="font-size:11pt;">​This resource is available through </span><a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Training" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" style="font-size:11pt;">SNF QRP Training</a><span style="font-size:11pt;"> </span><span style="font-size:11pt;">page. Each course includes interactive exercises to test your understanding. </span><br></div><div><br></div><div><span style="font-size:11pt;">To access the individual courses, click on the links below: </span></div><div><br></div><div><ul><li><a href="https://pac.training/courses/gg_course1_2024/#/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Course 1: Section GG Data Accuracy and Quality Measures</a><br></li><li><a href="https://pac.training/courses/gg_course2_2024/#/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Course 2: Prior Functioning and Prior Device Use Items</a><br></li><li><a href="https://pac.training/courses/gg_course3_2024/#/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Course 3: Accurate Coding for GG0130 and GG0170 Items </a><br></li><li><a href="https://pac.training/courses/gg_course4_2024/#/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Course 4: Understanding Admission and Discharge Performance for GG0130: Self-Care Item</a><br></li><li><a href="https://links-2.govdelivery.com/CL0/https://pac.training/courses/gg_course5_2024/%23//1/010101918fdba6cb-3a752c12-60d3-43aa-b264-e05c70cab302-000000/buws0d3IlpAWL6CH40cCdZpqgrj3Ii-dEW96Wa8Zi_M=367" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank" style="font-size:11pt;"></a><a href="https://pac.training/courses/gg_course5_2024/#/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Course 5: Understanding Admission and Discharge Performance for GG0170: Mobility Items​</a><br></li></ul></div><div><br></div><div>If you have questions about accessing resources or feedback regarding the training, please email the <a href="mailto:PACTraining@EconometricaInc.com" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">PAC Training Mailbox</a>. Content-related questions should be submitted to the <a href="mailto:SNFQualityQuestions@cms.hhs.gov" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">SNF QRP Help Desk​</a>. <br></div><p>​</p>CMS has released an updated series of web-based training courses that provide an overview of the assessment and Section GG guidance found in the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.19.1.
Survey Tip - Transfer and Dischargehttps://www.ahcancal.org/News-and-Communications/Blog/Pages/Survey-Tip-Transfer-and-Discharge-.aspxSurvey Tip - Transfer and Discharge8/20/2024 4:00:00 AM<div>A new survey tip has been posted to the <a href="/Survey-Regulatory-Legal/Pages/default.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">AHCA Survey Regulatory page</a> for your review. In the Survey Tip section, you'll find information related to recent survey trends, including the latest on regulations for the transfer and discharge of residents. This <a href="/Survey-Regulatory-Legal/MemberOnlyDocs/Survey%20Tips/Survey%20Tip%20for%208.21.24.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">tip sheet</a> focuses on F622 - Transfer and Discharge, providing essential guidance. </div><div><br></div><div>For more insights, don't miss our webinar, <em><a href="https://educate.ahcancal.org/products/discharges-making-the-safest-transition-for-your-residents" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Discharges- Making the Safest Transition for Your Residents</a></em>. If your facility requires additional training or technical assistance, particularly in caring for residents with Behavioral Health needs or Substance Use Disorders (SUD), please reach out to the <a href="https://www.bing.com/ck/a?%21&&p=e7a7fa4ec5caa2e7JmltdHM9MTcyMzY4MDAwMCZpZ3VpZD0yNGUwZGMyMS0xMjJiLTY1YzItMDQ0MS1jZWFmMTM2NDY0ZDUmaW5zaWQ9NTIwNg&ptn=3&ver=2&hsh=3&fclid=24e0dc21-122b-65c2-0441-ceaf136464d5&psq=centers+of+excellence+for+behaviors+in+nursing+facilities&u=a1aHR0cHM6Ly9udXJzaW5naG9tZWJlaGF2aW9yYWxoZWFsdGgub3JnLw&ntb=1" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Center of Excellence for Behavioral Health in Nursing Facilities</a>. </div><div><br></div><div>For any questions, email us at <a href="mailto:regulatory@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">regulatory@ahca.org​</a>.  <br></div><p><br><br></p>A new survey tip has been posted to the AHCA Survey Regulatory page for your review.
Healthcare Interpretations Task Force Address Several Life Safety Issueshttps://www.ahcancal.org/News-and-Communications/Blog/Pages/Healthcare-Interpretations-Task-Force-Address-Several-Life-Safety-Issues.aspxHealthcare Interpretations Task Force Address Several Life Safety Issues8/20/2024 4:00:00 AM<p></p><div>A little-known group met and made some important and impactful interpretations recently that could directly affect your life safety survey and your organization’s Life Safety Code® (LSC) compliance. The Healthcare Interpretations Task Force (HITF) is a unique coalition of health care organizations and authorities with jurisdiction that come together annually to evaluate and debate interpretations of specific questions related to NFPA codes and standards.  Their intent is to provide consistency in how the various codes and standards are interpreted and applied.   </div><div><br></div><div><span style="font-size:11pt;">The group met this past June in Orlando during the NFPA’s annual conference and exposition. The meeting and subsequent balloting of voting members resulted in several interpretations that have direct impact on healthcare organizations required to maintain compliance with the Life Safety Code®, such as those under the auspices of CMS. While there were numerous topics discussed, providers should be aware of the following three (3) interpretations:  </span></div><div><br></div><div><ul><li><strong>Alcoves / Hazardous Areas</strong> <br>Alcoves off the corridor are often a key location for storing small quantities of carts, wheelchairs, and various other items. The HITF clarified that it is not the intent of the LSC to limit the number of alcoves in an exit access corridor in a healthcare occupancy. They also agreed that it is not the intent of the LSC to aggregate the areas of alcoves. This is an important and beneficial interpretation for all healthcare providers as some AHJs have been aggregating alcove areas off the corridor. Once they exceed 50 square feet in total, they consider the alcoves as “hazardous areas”. The hazardous area designation does not allow the spaces open to the corridor to be used for limited storage. This interpretation clarifies that each alcove is an individual space, and if each space is not more than 50 square feet, it can be utilized for limited storage.  <br><br></li><li><strong>Delayed Egress Locking Systems</strong> <br>The LSC permits healthcare occupancies to have delayed egress locking systems. These are generally systems where a push bar on a door is engaged, an alarm sounds, and 15 to 30 seconds later the door automatically unlocks. There are a variety of specific requirements around the door hardware, signage, and operation.  The LSC language has not caught up with technology as it relates to delayed egress locking hardware.  The HITF clarified that items such as card readers can be utilized to bypass doors and reset door locks.  A key is not the only permissible method.  The interpretation also clarifies that the locking hardware is not limited to a push bar even though the requirement for the signage indicates “push” until the alarm sounds.  There are other delayed egress door locking arrangements on the market that can be utilized.    <br><br></li><li><strong>Alcohol Based Hand Rub Dispensers</strong> <br>The LSC requires alcohol-based hand rub dispensers to be horizontally separated by 48 inches. However, it is not uncommon to have a dispenser on the wall adjacent to a room door with another dispenser found on the wall inside the room. The HITF clarified that the 48-inch separation requirement is not intended to apply when one dispenser is in the corridor and another dispenser is located right around the corner by the door inside a room.  </li></ul></div><div><br></div><div><span style="font-size:11pt;">You can find detailed information about the HITF including past meeting minutes and interpretations on the <a href="https://www.nfpa.org/for-professionals/codes-and-standards/standards-development/technical-committees/advisory-and-non-nfpa-committees/healthcare-interpretations-task-force" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">NFPA website</a>.  You can also email life safety related questions to <a href="mailto:emergencyprep@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">emergencyprep@ahca.org</a>.   </span></div><p>​</p>A little-known group met and made some important and impactful interpretations recently that could directly affect your life safety survey and your organization’s Life Safety Code® compliance.

 ‭(Hidden)‬ Toolkit

HealthCap Risk Manageme​​nt Services has released the 2022 Elopement ​Prevention & Management Toolkit.

 Focus F-Tags: Guidance

In 2022, CMS released new guidance for Requirements of Participation Phase 3. The following summaries were created to provide detailed information regarding the updates to several F-tags. 

Please refer to Appendix PP Gu​​idance to Surveyor for Long Ter​m Care Facilities​​​ for the most up to date regulations and guidance.​​ ​

 F-Tag Action Briefs & Much More on ROP

Additional resources and tools to help you navigate the ROP are available on ahcancalED, including F-Tag Action Briefs, which complement the sum​m​a​ries above and highlight implementation strategies and tips​.  
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Phase 3 Interpretive Guidance – Delayed

Phase 3 of the Requirements of Participation (RoP) went into effect on November 28, 2019. However, as the Centers for Medicare & Medicaid Services (CMS) announced in a memo (QSO-20-03-NH) released on November 22, 2019, CMS will not be releasing the interpretive guidance (IG) for Phase 3 until the second ​quarter of 2020.  Read More>>​