Harmony Healthcare Blog

New Long-Term Care Survey Process: Seven Parts

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Thu, Aug 24, 2017

Find me on:

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

7steps.jpgLong-term regulatory changes can be daunting at best and the New Long-term Care Survey Process is no different.  Harmony Healthcare International (HHI) does its best to synthesize new information and present it in a manner that is easy to digest.  With that in mind, let’s review the new survey process in seven parts. 

Seven Parts to New LTC Survey Process

  1. Off-Site Prep
  2. Facility Entrance
  3. Initial Pool Process
  4. Sample Selection
  5. Investigations
  6. Ongoing Activities
  7. Potential Citations 
  1. Off-Site Prep

    The Team Coordinator (TC) completes the off-site preparation and specifically reviews: 
  • Repeat deficiencies
  • Results of last Standard survey
  • Complaints
  • FRIs (Facility Reported Incidences- federal only)
  • Variances/waivers 

All of the necessary documents are printed: 

  • Unit and mandatory facility task assignments
  • Dining
  • Infection Control
  • Skilled Nursing Facility (SNF) Beneficiary
    • Protection Notification Review
  • Resident Council Meeting
  • Unit and facility task assignments, continued
    • Kitchen
    • Medication administration and storage
    • Sufficient and competent nurse staffing
    • QAA/QAPI 

There is no offsite preparation meeting. 

  1. Facility Entrance 

Upon arrival, the Team Coordinator (TC) conducts an Entrance Conference and requests: 

  • Updated Entrance Conference Worksheet
  • Updated Facility Matrix 

Updated Facility Matrix (Draft):

 Upon completion, there is a brief visit to the kitchen and then the Surveyors proceed to assigned areas.

  1. Initial Pool Process

    The initial pool process includes selecting the sample size based on census.  The surveyor requests names of new admissions.  
  • 70% selected off-site
  • 30% selected on-site by team (approximately 8 residents):
    • Vulnerable
    • New Admission
    • Complaint
    • FRI (Facility Reported Incidents- federal only)
    • Identified concern 

Resident Interviews 

  • Screen every resident
  • Suggested questions—but not a specific surveyor script
  • Must cover all care areas
  • Includes Rights, QOL, QOC
  • Investigate further or no issue 

Surveyor Observations 

  • Cover all care areas and probes
  • Conduct rounds
  • Complete formal observations
  • Investigate further or no issue 

Resident Representative/Family Interviews 

  • Familiar with the resident’s care
  • Complete at least three during initial pool process or early enough to follow up on concerns
  • Sampled residents if possible
  • Investigate further or no issue
  • “Non-interviewable” residents 

Limited Record Review                                               

The Surveyors conduct limited record review after interviews and observations are completed prior to sample selection. 

Records reviewed include: 

  • All initial pool residents: advance directives and confirm specific information
  • If interview not conducted: review certain care areas in record
  • Confirm insulin, anticoagulant, and antipsychotic with a diagnosis of Alzheimer’s or dementia, and PASARR (Pre-Admission Screening and Resident Review)
  • New Admissions – broad range of high-risk medications
  • Extenuating circumstances, interview staff
  • Investigate further or no issue 


The Surveyors will observe the first full meal.  They will: 

  • Cover all dining rooms and room trays
  • Observe enough to adequately identify concerns
  • If feasible, observe initial pool residents with weight loss
  • If concerns identified, observe another meal 

Team Meetings 

The Surveyors will conduct Brief Team Meeting at the end of each day to assess: 

  • Workload
  • Coverage
  • Concerns
  • Synchronize and share data (as needed) 

  1. Sample Selection 

The Sample Selection will be prioritized using sampling considerations: 

  • Replace discharged residents selected off-site with those selected on-site
  • Allowed to replace residents selected off-site with rationale
  • Harm, SQC if suspected, IJ if identified
  • Abuse Concern
  • Transmission based precautions
  • All MDS indicator areas, if not already included 

Sample Selection – Unnecessary Medication Review 

  • System selects five residents for full medication review
  • Based on observation, interview, record review, and MDS
  • Broad range of high-risk medications and adverse consequences
  • Residents may or may not be in sample 
  1. Investigation 

An investigation occurs when concerns arise for sampled residents. 

  • Conduct investigations for all concerns that warrant further investigation for sampled residents
  • Continuous observations, if required
  • Interview representative, if appropriate, when concerns are identified
  • Majority of time spent observing and interviewing with relevant review of record to complete investigation
  • Use Appendix PP and Critical Elements (CE) Pathways 
  1. Ongoing and Other Survey Activities 

Closed Record Reviews 

  • Complete timely during the investigation portion of survey
  • Unexpected death, hospitalization, and community discharge last 90 days
  • System selected or discharged resident
  • Use Appendix PP and Critical Elements (CE) Pathways 

Facility Task Investigations 

  • Complete any time during investigation
  • Use facility task pathways
  • CE compliance decision 

Dining – Subsequent Meal, if Needed 

  • Second meal observed if concerns noted
  • Use Appendix PP and CE Pathway for Dining
  • Dining task is completed outside any resident specific investigation into nutrition and/or weight loss 

Infection Control 

Throughout survey, all surveyors should observe for infection control. 

  • Assigned surveyor coordinates a review of influenza and pneumococcal vaccinations
  • Assigned surveyor reviews infection prevention and control, and antibiotic stewardship program 

SNF Beneficiary Protection Notification Review 

  • A new pathway has been developed
  • List of residents (home and in-facility)
  • Randomly select three residents
  • Facility completes new worksheet
  • Review worksheet and notices 

Kitchen Observation 

In addition to the brief kitchen observation upon entrance, the Surveyor will: 

  • Conduct full kitchen investigation
  • Follow Appendix PP and Facility Task Pathway to complete the kitchen investigation 

Medication Administration 

  • Recommend nurse or pharmacist
  • Include sample residents, if opportunity presents itself
  • Reconcile controlled medications if observed during medication administration
  • Observe different routes, units, and shifts
  • Observe 25 medication opportunities 

Medication Storage 

  • Observe half of medication storage rooms and half of medication carts
  • If issues, expand medication room/cart 

Resident Council Meeting 

  • Group interview with active members of the council
  • Complete early to ensure investigation if concerns identified
  • Refer to updated Pathway 

Sufficient and Competent Nurse Staffing Review 

This is  a mandatory task, and the reference is the revised Facility Task Pathway. The intent is to assess the sufficiency and competency of staff.  Throughout the survey, the Surveyors are assessing if staffing concerns can be linked to Quality of Life (QOL) and Quality of Care (QOC) issues. 


The Surveyors investigate specific concerns.  The goal is to eliminate redundancy with LSC: 

  • Disaster and Emergency Preparedness
  • O2 storage
  • Generator 
  1. Potential Citations
    The Survey Team collaborates on compliance determinations.  They identify Scope and Severity. They conduct an exit conference and relay potential areas of deficient practice to the Provider.

We hope this Blog Post helps you in your quest for Survey Preparedness! 

Stayed tuned as Harmony Healthcare International (HHI) continues to update you on the new survey process along with all other regulatory changes.

Harmony Healthcare International (HHI) is available to provide assistance You can contact us by clicking here. Looking to train your staff?  Join us in person at one of our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

Additional Information:

Additional information about the survey process and implementation can be found at: 


So much information, so little time to learn it!
Join us for a “Party in Our Brain” November 2nd & 3rd, 2017 at Foxwoods Resort

6th Annual LTPAC Symposium
Click Here to Register
harmony20 October 29-30 2020 Encore Boston Harbor

Tags: Long-Term Care Survey Process

Subscribe to The HHI Blog

Posts by Topic

see all
New Call-to-action

Stay connected!