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CMS Surveys: Unexpected Requirements and Shifting Standards

If the COVID pandemic has taught the healthcare and long-term care industries anything, it’s that standards can change at a moment's notice. Starting in March of 2020 and continuing to this day, nursing homes and long-term care facilities were rocked by unexpected requirements and shifting standards, all levied by the the Centers for Medicare & Medicaid Services (CMS).

However, CMS doesn’t operate unilaterally and the center doesn’t cast arbitrary rules. Oftentimes, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) calls on CMS to take various forms of action. For example, the HHS OIG recently called on CMS to make significant changes to nursing home operations and oversight in light of new data on COVID infection rates.

This isn’t the first time OIG has focused on the nursing home sector—and it certainly won’t be the last. Procedures shift and new initiatives are launched on a regular basis in this industry, with Immediate Jeopardy surveys often leading the pack.

So how can you prepare your nursing home teams for such scenarios? Let’s examine a few of the most trusted methods.

1. Always Stay Updated on Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)

Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) are standards developed by CMS that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. Such health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.

CoPs and CfCs apply to the following health care organizations:

  • Ambulatory Surgical Centers (ASCs)
  • Community Mental Health Centers (CMHCs)
  • Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  • Critical Access Hospitals (CAHs)
  • End-Stage Renal Disease Facilities
  • Federally Qualified Health Centers
  • Home Health Agencies
  • Hospices
  • Hospitals
  • Hospital Swing Beds
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
  • Organ Procurement Organizations (OPOs)
  • Portable X-Ray Suppliers
  • Programs for All-Inclusive Care for the Elderly Organizations (PACE)
  • Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  • Psychiatric Hospitals
  • Religious Nonmedical Health Care Institutions
  • Rural Health Clinics
  • Long Term Care Facilities
  • Transplant Centers

Non-compliance with CoPs and CfCS can bring about major consequences. For example, various sanctions may be imposed upon the provider, including a corrective action plan, monetary penalties, and increased reporting requirements.

The best way to stay updated on CoPs and CfCs is to keep educating your team. You should always take advantage of free training seminars and any educational opportunities regarding these two crucial sets of standards.

2. Always Have Your Reports Ready

Be aware of what information the surveyor will want and be ready to run those reports. The surveyors want specific details such as the number of unduplicated admissions in the last 12 months or the current caseload with diagnosis and discipline. You should always have reports such as those ready the minute the surveyor enters the facility. This can help ensure your team stays ahead of the curve.

What’s more, reports should be built by someone who really understands report writing and what is expected of them. If necessary, run reports multiple times until you feel confident in the results. And don’t be afraid to mark the reports you know you’ll need for the CMS survey. This way they are easily accessible.

3. Always Be Organized

Keeping your facility organized is all about consistency, knowing where documentation is located, and creating organizational structure.


Make sure that each clinician keeps records in the same way. If one team member works entirely in the digital documentation, but another writes everything down on paper, you could end up with major reporting issues.


It’s critical that you understand as an agency where important files are documented. Surveyors want to have full confidence that you know where everything is located and all files are organized. When a surveyor asks for a document, your stress levels will ease when you can find the file and print it without any fuss.


An organizational cheat sheet can make it easier to locate key pieces of information. Set up your files so that patient charts are organized based on a predetermined set of standards. When surveyors arrive, you can simply grant them access to the cheat sheet.

4. Conduct Peer Reviews

In preparation for your CMS survey, you can subject your facility to a peer review. This is a review by health care practitioners of services ordered or furnished by other practitioners in the same professional field.

This fresh, third-party perspective can help staff understand certain shortcomings that previously may not have been as clear. While asking another agency to “audit” yours can be intimidating and somewhat threatening, it can also be extremely beneficial. Other agencies might be able to fill certain knowledge gaps at your facility, and they might actually have a window into a certain set of standards that perhaps you missed. Consider partnering with another agency to conduct checkups and official peer reviews.

5. Find a Network of Support

Conducting peer reviews and opening your facility to the same reviews is a concrete indicator that when it comes to nursing homes, there is strength in numbers. Joining an organization that has your back in the face of CMS surveys and immediate jeopardy scenarios can serve to prepare your facility for even the most unforeseen circumstances.

There are many regional networks across the country that can offer membership to nursing homes and long-term care facilities. For example, the Empire State Association of Assisted Living, based in New York State, offers members a vast array of resources and opportunities. This includes:

  • The chance to play an active role in shaping the future of care
  • A peek into laws that are not yet in regulation, helping you stay ahead of compliance
  • Access to information and technical support
  • Educational tools, peer networking, and professional development

Becoming a member of such an organization helps you understand what is expected of you as a nursing home and can provide a pathway toward total compliance, no matter how CMS standards shift.

Qsource is another wellspring of support. As a Quality Improvement Organization (QIO), we assist an array of care facilities to meet modern day challenges. Our solutions can help facilitate healthcare quality, as we supply practical solutions to improve care experience for providers and patients. We exist in the healthcare ecosystem—as such, we are well versed in compliance standards both current and on the way.

Key Takeaway

CMS survey compliance does not consist of a series of static rules. Instead, the standards often fluctuate with the times. This fact can wreak havoc on a nursing home facility’s ability to stay on top of standards. But when you connect with an organization such as Qsource, you are given access to a wealth of information covering current regulatory standards, as well as any shifting tides on the horizon in the industry.

Connect with Qsource and equip your team with all of the survey readiness tools they need to succeed!