Angi Livingston

We are seeing a drastic increase in adverse survey outcomes putting operators in precarious licensure situations pending a first, second or third revisit.  In addition, we are seeing multiple failed revisits with increased scope/severity.  

The State Operations Manual (SOM) Chapter 7 – Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities clearly defines the “course of action for certifying compliance based on the seriousness of the noncompliance and the number of revisits that have already occurred.” 

It also provides guidance on both paper reviews and onsite revisits. While certain circumstances require “mandatory onsite revisits,” others do not, and compliance may be determined through paper review.  The SOM includes a clear and specific chart, “Revisit/Date of Compliance Policy,” to guide surveyors and facilities on revisit requirements.  

As a third revisit is not guaranteed and must be approved by the Centers for Medicare & Medicaid Services regional office, achieving compliance on the first or second revisit is critical. Failure to clear on the second revisit places the facility at serious risk for termination of the provider agreement and loss of license because there is no assurance the third revisit will be approved, and the open survey cycle/six-month timeline quickly vanishes.

Our reviews of deficient practice associated with multiple failed revisits and resulting repeat deficiencies have identified that facilities are often recited for the same regulation. However, the actual identified deficient practice is different due to the facility’s failure to consider the entirety of the regulation and failure to take all necessary steps to address the entirety of the regulation.   

While the Plan of Correction must address the corrective action that will be taken for the resident(s) found to have been affected by the identified deficient practice and the resident(s) having the potential to be affected by the same deficient practice, the facility is required to be in compliance with the full regulation. Therefore, the survey agency will validate compliance based on the full regulation and the entirety of all regulations, not just the identified deficient practice.  

In preparation for a revisit, validate all components of the POC have been implemented.  It is also imperative to validate compliance with the full regulation that was cited, along with all regulations. Evaluate and audit all processes and systems to identify any area of noncompliance, implement corrective actions, incorporate them into QAPI and educate staff.  

Don’t let the old saying “can’t see the forest for the trees” cause a failed revisit.  Consider an impartial and objective approach to POC validation through the utilization of organizational internal resources not familiar with the facility/survey outcomes and/or a third party.   

Angi Livingston, MHA, BSN, RN, is a Senior Consultant at Formation Healthcare.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.