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Critical compliance elements for a smooth long-term care survey

We're talking staffing requirements, performance improvement projects, QAPI and training requirements according to CMS so you can negotiate your next survey with confidence.

Long-term care establishments have had the phase three regulations and guidance to surveyors for several months now but that doesn't mean that long-term care facilities have it all down to a T. Eldercare professionals and communities are still facing incredible strain which makes maintaining compliance challenging. Despite the difficulties that staffing shortages and changing regulations present, this article will help you to brush up on some of the finer points of CMS requirements so you can negotiate your next survey with confidence.

Nursing staff

With the continuing difficulties in acquiring and retaining nursing staff, you might well be left wondering what is expected and required by CMS relating to adequate staff levels.

In terms of staffing, your obligations as a nursing facility are:

  • To provide Licensed Nursing staff 24/7
  • To provide the quantity of staff advised in your facility assessment for staffing
  • To ensure that Registered Nursing staff cover at least 8 consecutive hours per day for 7 days a week.
  • To cater to the behavioral needs of residents with mental disorders or who have a history of substance abuse disorders
  • To appoint a Director of Food and Nutrition who has 2 or more years of experience and has completed a course of study in food safety and management
  • To provide an Infection Preventionist who is on-site and at least part-time. They should report to the Quality Assessment and Assurance Committee and your governing body

Binding Arbitration Agreements

Another element to be aware of is the necessity of Binding Arbitration Agreements. Each care facility must have a process in place ensuring that a resident does not have to physically sign as a condition of admission, or as a requirement for them to continue to receive care. The agreement must be fully explained to the resident or representative in a manner they can understand, and the resident can rescind their agreement within 30 days.

Why is this so important to iron out before your next survey? Well, according to nursing home compliance expert, Rebecca DeRousse, "Surveyors are likely to interview residents about whether their options for agreements were fully explained and understood prior to the completion of the agreement."

Because of this, make sure you have documented the steps you've taken as a health care provider to fully explain the agreement options to your residents and their representatives.  

PIPs or Performance Improvement Projects

Just like when you come across real pips in a bite of your mid-morning doctor-repelling apple, PIPs are inconvenient facts of life for care facilities, but they’re there for a reason. In this case, to prove that as a care provider, you are committed to constant improvement and to ensuring an outstanding level of care delivery to your nursing home residents. 

Your area of improvement should be identified as a result of your facility assessment, data collection, and analysis and you should be able to demonstrate at least one PIP annually that focuses on “high-risk or problem-prone areas” or on quality improvement in the absence of a deficiency. Pick your PIP wisely and commit to improvement, remembering that without PIPs in the world, it would sure be hard to keep growing.

Resident call system

According to phase 3 guidance, your resident call system is only compliant if:

  • Your system is functional (well, duh)
  • Calls are being answered
  • It is accessible to residents while sleeping, lying on the floor, and in every toilet, bathroom, or shower facility.

Of course, that's quite the tall order and the third point, in particular, can be hard to prove, so it's good to carefully consider and think tank ways of documenting and if necessary, redesigning room layouts to meet these requirements. Preferably before your next survey window. 

QAPI and Quality Assessment and Assurance Committees

It’s nothing explicitly new, but it’s always helpful to be reminded that your QAPI program should be data-driven. You should be able to demonstrate how data is collected and collated in efficient reports and how you translate that data into points for improvement.

Training requirements

What training must care staff complete in order to be compliant with current regulations? 

General training policies

Training must be given to, and completed by, every member of staff according to their roles including those who are providing services under a contractual arrangement, volunteers, as well as new and existing staff.

Rebecca DeRousse advises that “if a state surveyor comes in and sees a large number of agency staff, they’re really going to be paying attention to the training of that staff. So, I would be very careful to make sure that you’re able to prove that your agency staff has been trained in all these mandatory training requirements as well.”

A key aspect of your compliance in this area is documenting the ongoing training of your staff and being able to prove that staff and volunteers have been adequately trained before delivering any independent care to residents.

In addition to the above, all staff, whether they are direct caregivers or not, must complete training in the following areas:

  • Resident rights and facility responsibilities
  • Abuse, neglect, and exploitation
  • Quality assurance and performance improvement
  • Infection control
  • Compliance and ethics
  • Behavioral Health such as interpersonal communication and person-centered care


Your direct care staff must also receive communications training. This should cover the rights of residents to have access to forms of communication that are appropriate for them, including that information given to a resident should be in a language, form, and manner that the resident can understand. 

While the guidance for this is simple enough, any front-line senior care professional is going to be picturing at least one or two residents that are particularly difficult to communicate with effectively. It may be due to temperament, cognitive or other medical conditions, a language barrier, or cultural difference, but whatever the reason you find conversation hard with these people, we have to remember one simple fact: they have the right to be informed about their own care. It's up to the individual skilled nursing facility to make that happen. 

Final thoughts

While surveys can be stressful affairs for the staff and potentially disruptive for residents, they do serve an important purpose. Quality improvement is our constant goal as the carers and guardians of our seniors and in that respect, we differ in no way from the surveyors.

Hopefully, this article has given you an insight into some of the lesser, talked about points of compliance with the phase three standards. If you're looking for a more comprehensive guide to surviving your senior care community's next survey with a smile on your face then you might be interested in our free Webinar: Readiness for Phase Three Enforcement presented by Rebecca DeRousse of DeRousse Healthcare Consulting LLC. 

For more educational content such as articles, infographics, and free webinars straight to your inbox, please sign up for the Accora newsletter by filling in the form at the bottom of this page.

Staff Shortages
Long Term Care
Accora Team
FloorBed technology to help skilled nursing, rehabilitation and long term-care facilities prevent falls and fall-related injuries.
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