Skilled Nursing Facility State Surveys: What to Know and How to Prepare

Wound Care Specialist

Skilled Nursing Facility State Surveys: What to Know and How to Prepare

To maintain appropriate licensing and Medicare/Medicaid enrollment, SNFs must comply with state and federal regulations regarding staff and patient safety. Unannounced annual state surveys assess compliance. When standards are not met, SNFs are issued citations. Citations can lead to fines, costly corrective action, and lost business due to damaged reputation. 


One of the most common survey violations is Infection Prevention & Control. This means that understanding and preparing for state surveys is particularly important during COVID-19. One way to protect your SNF from violations is by working with skilled physicians who have experience with regulations and are prepared to advocate on behalf of the SNF with state auditors. 


At Vohra Wound Physicians, the nation’s most trusted wound care solution, physicians are prepared to advocate for SNFs. They are also prepared to help prevent survey violations. By working with Vohra, SNFs can provide their residents with excellent, in-house wound care. They can also mitigate the risk of survey violations and wound care litigation. 


Learn more about Vohra’s work with long-term care facilities.

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Skilled Nursing Facilities

What type of care is provided at Skilled Nursing Facilities?

Skilled Nursing Facilities (SNFs) provide round-the-clock, on-site medical support. SNFs have short-term rehabilitation services for those recovering from illness or injury. They also offer long-term care for those with ongoing need and chronic medical conditions. SNFs employ experienced medical professionals including RNs, LPNs, and CNAs. 


When do patients need skilled care?

A patient needs skilled services for a medical condition that’s either:

  • A hospital-related medical condition treated during a qualifying 3-day inpatient hospital stay, even if it was not the reason they were admitted to the hospital for; or

  • A condition that started while they were receiving care in the SNF for a hospital-related medical condition (for example, an infection that requires IV antibiotics while receiving SNF care).

Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. This health care is given when the patient needs skilled nursing or skilled therapy to treat, manage, and observe the condition, and evaluate their care.


How do families decide whether a SNF is right for their loved ones?

When it becomes unsafe for seniors to live alone and/or care for their own medical needs, their loved ones may determine that a residential care facility is the best option. If patients require skilled care, their families will likely research top skilled nursing facilities. Here are factors they will typically consider when choosing a SNF:

  • SNF citations. Has the SNF demonstrated successful compliance with state surveys? Do they have Medicare and/or Medicaid certification? If they have ever had violations, have they addressed them promptly and thoroughly

  • Infection rate. What is the frequency of infection, and how is it handled

  • Facility maintenance. Is the SNF clean and well-tended? 

  • Schedule. Are there regular mealtimes with healthy foods? How is medication dispensed? What activities are available for residents?

  • Resident experience. Do the residents seem happy and engaged? Are they well-groomed and properly cared for? 

  • Staff. What is the staffing level (ratio of staff to residents, distribution of staff throughout the facility, etc.)? How frequent is staff turnover? How do staff respond to patient and family questions and concerns? Are they prepared for emergencies?

There are many factors that go into choosing a SNF, but the most critical elements are SNF citations and number of infections. These are two of the clearest indicators of SNF health and safety compliance. SNF safety compliance results are also critical because they determine Medicare/Medicaid coverage. Therefore, it is important that SNFs implement thorough infection protocols and prepare to demonstrate compliance with regulations during annual state surveys


Vohra Wound Care Centers of Excellence

Wound care management is another factor that should be considered when assessing SNFs. SNFs with superior wound management programs can be certified as Vohra Wound Care Centers of Excellence, a valued national distinction. To earn this certification, SNFs must meet strict criteria and gain approval by a panel of experienced physicians. Approved facilities have been identified as possessing excellent wound care, above-average patient outcomes, and ongoing commitment to education and improvement in wound care. Identifying a Vohra Wound Care Center of Excellence near you is a valuable way to find physician-recommended SNFs.

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State Surveys

Annual federal nursing home surveys assess SNF safety and quality of care and have publicly available results. They are important for patient safety, facility success, and family trust. 


What is the CMS?

The Centers for Medicare and Medicaid Services (CMS) is an agency that oversees Medicare and Medicaid. It is the division of the U.S. Department of Health and Human Services that creates and implements regulations for health care providers. This includes hospitals, home health agencies, SNFs, and other facilities.  


What do state surveys entail?

During state surveys, auditors comprehensively review SNF policies, patient records, and procedures detailing implementation of care. Surveyors review prior survey results, investigate instances of policy deviation, and ensure that everything is carefully documented, and proper protocols have been developed.


How are SNFs graded?

SNFs are graded on a Five-Star Quality Rating System. Each SNF receives an overall score out of five stars, as well as an individual rating for three key components:

  • Health inspections. This score depends on the three most recent health inspections and any health complaint investigations. 

  • Staffing. This rating depends on average hours of care provided for each resident as compared to their level of need. 

  • Quality measures (QM). The QM score depends upon how the SNF scores on 15 criteria assessing care for resident physical and clinical needs.

This system was created to aid families, caregivers, and patients in their assessment of SNF quality. The breakdown into three sections also helps identify areas of deficiency and guide the questions that they may want to ask during a SNF visit. Failure to meet requirements can lead to punishments including fines, payment denials, and patient transfers. Failure can also lead to loss of ability to participate in Medicare and Medicaid programs.


How are nurses involved in state surveys?

Nurses are the lifeblood of SNFs, so they are responsible for addressing many of the questions asked during a survey. Among other things, SNF nurses are responsible for distributing medicine, monitoring patient vitals, performing wound care, overseeing mealtimes, and ensuring comprehensive documentation. As such, during surveys they may be asked questions about resident care protocols, patient abuse or injury, and emergency responses. Additionally, many state surveyors are or were practicing nurses, so they have experiential understanding of SNFs.

How are physicians involved in state surveys?

Physicians regularly assess SNF residents and make determinations about ongoing care, so they play an important role in state surveys. To prevent violations, SNFs reach out to physicians and have them explain specifics of patient circumstances to auditors. For example, SNFs often ask physicians to explain wound healing processes to prevent potential violations.

When SNFs partner with Vohra, Vohra physicians regularly visit the SNF to deliver treatment and educate nurses on wound care. In doing so, physicians grow familiar with SNF policies and procedures and are prepared to advocate for the SNF during state surveys. For example, development of pressure ulcers and slow-healing wounds are sometimes unavoidable based on patient circumstance and risk factors. However, they frequently lead to state survey violations. Vohra Wound Specialists can explain why a wound has not healed or how it developed to prevent violations. Vohra Wound Physicians have also been shown to significantly improve patient outcomes and prevent infections and wound-related hospitalizations. Partnering with Vohra often leads to improved results on CMS surveys and mitigates the risk of violations.


How have CMS criteria changed in recent years?

CMS regulations are regularly updated to address modified knowledge of best practices. Changes primarily focus on measures that will improve resident safety and reduce hospitalizations. There were several new nursing home regulations implemented in 2019. Health inspection star ratings were updated and changes were made to threshold staffing requirements. Notably, SNFs now automatically receive a one-star rating if they have four or more days per quarter without a registered nurse on site. In addition, Quality Measure ratings now distinguish between long-term and short-term stays, as their SNF experiences are different: short-term residents are typically focused on improving their health or healing from injuries, whereas long-term residents are maintaining regular medical care. 

There have also been
changes to CMS state surveys in the wake of COVID-19. Non-emergent surveys have been suspended to shift inspector focus to the most pressing safety threats: spread of infection and resident mistreatment or abuse. CMS is encouraging state survey providers to keep SNFs informed of updated practices on COVID-19 infection control.


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Survey Violations

What are F-tags?

When state auditors identify an instance of noncompliance at a SNF, they mark the violation using a federal tag numbering system. Criteria for long-term care facilities is listed in subsection F of federal regulations, so SNF violations are called F-Tags. Each F-Tag corresponds with a long-term care facility federal regulation. Nursing home state survey tags are updated regularly to guide surveyors, reflect updated knowledge, improve survey integrity, and decrease nationwide standard variability. 

When a SNF receives an F-Tag, it affects its survey rating. It is also reported on federal websites, such as the state’s Department of Health website, and must be publicly displayed at the facility. F-Tag penalties depend on the nature of noncompliance. F-Tag deficiencies are categorized based on their capability for harm. This categorization ranges from violations with potential for minimal harm up to violations that pose immediate risk to residents. Auditors also determine whether F-Tags are isolated or symptoms of a pattern. Deficiency responses must be corroborated, so it is critical that SNFs have physicians available to support responses. 


What are common F-tags?

Understanding frequent SNF deficiencies can help your facility avoid costly citations. Here are some common nursing home survey tags and their definitions:

  • F-880 – Infection prevention and control. This F-Tag is the most cited deficiency. It seeks to ensure that residents are provided a sanitary environment and that there are appropriate infection procedures. To avoid this F-Tag, SNFs must have readily-available written policies and a comprehensive system for recording and responding to infections.
  • F-689 – Free of accidents, hazards/supervision/devices. SNFs must prevent resident accidents by keeping facilities free of foreseeable hazards and providing adequate supervision and assistance. This F-Tag can be avoided by conducting detailed facility assessments and implementing interventions as necessary. 
  • F-656 – Develop/implement comprehensive care plan. This requirement entails that each patient has a comprehensive care plan with clear objectives, timeframes, and assessment criteria. This F-Tag can be avoided by working with qualified physicians that are prepared to map out patient care, such as Vohra wound physicians. 
  • F-684 – Quality of care. This regulation seeks to ensure that patient care is focused on both medical need and patient preference. It also includes appropriate recognition of risk factors, worsening condition, and psychosocial well-being. 
  • F-686 (formerly F-314) – Pressure ulcers. Surveyors seek to ensure that residents are not developing pressure ulcers and that those that develop pressure ulcers are appropriately treated. F-Tag 686 can often be avoided if documentation indicates that a resident was at high risk for a pressure ulcer or that their behavior and conditions hindered appropriate pressure ulcer prevention. Wound physician advocacy is another helpful aspect of F-686 prevention. 
  • F-812 – Food procurement/storage. This F-Tag assesses compliance with food safety regulations. This includes confirming and abiding by expiration dates, keeping foods properly sealed and stored, and ensuring food quality.

How do facilities respond to F-Tag deficiencies?

When a facility receives an F-Tag, they may face penalties depending on the severity of the violation. They must also complete their portion of CMS 2567. This is a form in which state auditors note deficiencies and the SNF fills in and then submits a corresponding plan of correction (POC). The POC must be approved for the SNF to maintain certification. POCs are critical for facility compliance and are typically developed through collaboration between nurses, physicians, Chief Nursing Officers, and other SNF leadership.

F-Tags can also lead SNFs to face litigation from residents or their loved ones. The risk of wound care litigation can be significantly decreased if SNFs employ specialized wound care physicians. 


How should SNFs prepare for CMS surveys to prevent violations?

In order to prevent violations, SNFs must maintain a high level of survey readiness. This preparation can include maintaining meticulous records, creating a survey binder, and training staff members. Here are some nursing home state survey tips:

  • Maintain comprehensive patient records. During state surveys, auditors typically ask to review the prior three months of facility and patient records. The status of every resident and the details of their care must be clearly documented and regularly audited for clarity and integrity. As records become increasingly digitized, this may require confirmation that records are consistent across formats. The integrity of documentation can be assessed by performing regular “mock surveys” and then addressing shortfalls. The Vohra wound care portal enables quick and easy review of patient care. 
  • Conduct regular staff training. Ensure that all staff members are aware of CMS surveys and assessment criteria. Make sure that all employees can clearly explain their job function, regular hours, and patient care practices. Prepare them to respond to common survey questions and F-Tag concerns.
  • Implement a Quality Assurance and Performance Improvement (QAPI) program. Develop a written QAPI program aimed at optimizing resident quality of care and quality of life. This plan can be regularly updated and shown to auditors during surveys.
  • Perform regular rounds. This will keep staff members up to date on patient conditions and support document maintenance.
  • Ensure physicians are prepared to address violation concerns. Build relationships with physicians or partner with a physician group such as Vohra Wound Physicians so that there are experts on hand to address concerns about patient care and prevent F-Tags

State surveys and COVID-19

COVID-19 has reinforced the need for standard infection control, particularly within senior care facilities. CMS has temporarily suspended non-emergent surveys, and SNFs are implementing increased health and safety protocols. CMS is also continuously releasing information and guidance around nursing home infection management response. 

SNF Safety and State Surveys

To achieve strong CMS survey results, SNFs must uphold high standards of care and practice continuous survey readiness. This necessitates staff preparation: SNF employees must be equipped to respond to survey inquiries and physicians must be on hand to explain potential discrepancies.

By partnering with Vohra, SNFs can improve patient outcomes while protecting themselves from F-tags. Vohra physicians are prepared to advocate for SNFs and to discuss patient care with state auditors to avoid unnecessary F-tags and achieve higher CMS scores. Learn more about
how Vohra can help SNFs.

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Author: Janet S. Mackenzie, MD, ABPS, CWSP, AAGP

Janet S Mackenzie MD, ABPS, CWSP, AAGP is the Chief Medical Officer at Vohra Wound Physicians. She has been with the company since 2013 and has almost 30 years of wound care experience as both a plastic surgeon and a wound care specialist. After obtaining a Master’s degree in Education, she obtained her Medical Degree from the University of Pennsylvania Perelman School of Medicine. She trained in general surgery at Dartmouth Hitchcock Medical Center and plastic surgery at McGill University. She is board certified by the American Board of Plastic Surgery, the American Board of Wound Management, and the American Board of General Medicine, and is a Certified Wound Specialist Physician (CWSP).

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