CMS Updates FAQ on Care Center Surveys

Posted on February 14, 2018 by Jonathan Lips

Care centers will find it valuable to review the “Frequently Asked Questions Related to Long Term Care Regulations, Survey Process, and Training” posted on the CMS webpage dedicated to the requirements of participation and survey process.  

You will find the FAQ listed first among the available Downloads. The document addresses questions from providers and surveyors.  

It answers this question from a provider about the requirement to provide a written summary of the baseline care plan, as an example: 

How long do we have to we have to give the family a written summary baseline careplan? I’m aware the baseline careplan must be made in 48 hours but unclear how much time a written summary of plan to give to family.

Answer: At F655, the guidance states, “The facility must provide the resident and the representative, if applicable with a written summary of the baseline care plan by completion of the comprehensive care plan.” This means the resident or their representative must be provided a written summary before the completion of the comprehensive care plan.

Additionally, if the comprehensive assessment identifies changes which would result in a different approach or goal on the comprehensive care plan, these changes must also be reflected in the summary. This is reflected in the following guidance, which goes on to say “Given that the baseline care plan is developed before the comprehensive assessment, it is possible that the goals and interventions may change. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident’s goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative, if applicable.”

And here is an example of a surveyor question:

Question: When conducting a Post Survey Revisit (PSR) for a survey conducted prior to November 28, 2017, which regulation set should be used?

Answer:  When conducting a PSR for a survey conducted prior to November 28, 2017 the State Survey Agency should use the regulation set in effect during the survey for which the revisit is being conducted. The reason for the PSR is to ensure the facility has corrected areas of noncompliance found during the previous survey.  Some Considerations: * If the survey team is conducting a complaint survey alongside the revisit survey, there should be two separate shells created. A revisit shell with the regulation set used to conduct the previous survey that is driving the revisit and a second shell for the complaint that includes the current regulation set. * If the survey team identifies newly discovered areas of concern during the revisit survey that are serious in nature, a new survey event should be created in ACO (new shell) that includes the current regulation set as of November 28, 2017.

CMS updates the document regularly, which should make it a valuable resource to members going forward.