The Survey Process

Measuring Compliance in the Nursing Home Environment


The Long Term Care Inspection Process“Quality means doing it right when no one is looking.”
Henry Ford

Long term care facilities play an important role in the delivery of senior health care to an aging population within the United States. Along with retirement centers, home health care services and assisted living facilities, nursing homes provide vital care and services to elders and support to their family and loved ones.

This article will summarize the long term care survey process, one which measures long term care services by compliance with federal regulations. As of April 2005 there were approximately 16,000 nursing homes in the United States. A large portion of the individuals residing in these facilities receive care provided by Medicare and Medicaid funding. Facilities are required to be in compliance with federal regulations. The Centers for Medicare and Medicaid Services (CMS), oversees the Medicare and Medicaid programs and contracts with individual States to monitor long term care facilities and to conduct onsite inspections. Within individual States it is typically the Health Department which conducts the survey inspections. The purpose of these inspections is to determine whether the nursing center meets the minimum Medicare and Medicaid quality and performance standards. In the course of each survey inspection process, the survey team evaluates the care within a center and determines whether that care and service is provided in accordance with regulatory requirements. These surveys are unannounced and take place every 9 to 15 months.

Prior to conducting the survey, the survey team reviews a broad collection of information. This information includes the nursing homes’ previous survey history (the OSCAR report) which outlines four years of compliance history, the center’s quality indicator report (which presents resident specific chronic and post-acute care measures), as well as information from the State Ombudsman Office, in addition to any complaint investigations or occurrence reports for the center.

Utilizing this information, the survey team evaluates many different aspects of compliance with federal regulations. The team interviews residents, staff and family members. It evaluates regulatory compliance in areas including nursing care, medication administration, resident dignity, environmental quality, dietary services, recreational activities and medical record review, among multiple other areas. During this process, if the care and service present what is termed a deficient practice, that is, a practice which does not meet the compliance requirements, the survey team cites a deficiency. Importantly, the deficiency is categorized by the survey team and is assigned a scope and severity level. The scope of a deficiency identifies if the deficient practice is isolated in nature, presents a pattern or is widespread. The severity of a deficiency identifies if the deficiency had no actual harm or outcome, had the potential for harm or resulted in actual harm.

For a variety of reasons, nearly all nursing home surveys result in the citation of deficiencies. When evaluating a specific nursing homes survey history, it is important to look at whether the nursing home’s survey performance includes deficiencies which were less or greater than the statewide average for all nursing homes. Also, the specific kind of deficiency as well as its related scope and severity are very important, reflecting that deficiencies with lower scope and severity reflect much less concerning compliance concerns.

Following a survey, the nursing home receives a list of deficiencies (the 2567) and is given ten days to submit a plan of correction, which is then followed up with a follow-up survey to determine the implementation of the plan of correction by the center.