Nursing Home Survey Preparation Files

Every nursing home is required to have at least an annual survey in the range of every 9 – 12 months.  Of course, if you have complaints or are a focus facility, your survey will have a shortened span between them, every 6 months or so.

The goal of every nursing home administrator and facility should be to be survey ready everyday.  It does no good to not think about survey all year until the State survey team shows up.

So, to help prepare for the nursing home survey, here is a list of items that you should have ready.  I usually put these in a plastic file box, organized by number in hanging files.  You may organize them any way you wish.  Do NOT hand this box to the survey team.  Only give them what they ask for.  If you just hand over your information, it may lengthen your survey as it might trigger them to look in areas they had not planned on.

Also, do not hand them your originals.  Make them a copy, because there is a good chance you will not get it back.

Nursing Home Survey Preparation Files

1. Copy of Facility license
2. Current census – alphabetical with room numbers  (This is how it’s asked for)
3. Key facility personnel and their locations
4. Copy of Administrator’s license
5. Facility layout / floor plan
6. Surveys / Resident Identifiers for last 3 years
7. QI / QM – period of last 6 months
8. 802 – Roster Sample Matrix
9. 671 – LTC app for MCR/MCD
10. 672 – Census & Condition
11. 1513 – Disclosure of Ownership
12. Information on Resident Rights provided to residents
13. Meal times and dining locations
14. Copies of the menu, including therapeutic diets
15. Medication Pass times by unit
16. List of admissions in the past 30 days
17. List of residents transferred or discharged during past 3 months with destinations
18. Residents with planned discharges in the next 30 days
19. Current working schedule for nursing staff
20. Facility admission contract
21. Facility policies and procedures to prohibit abuse and investigate allegations of abuse
22. Designated person to answer questions regarding abuse and abuse prevention
23. Copy of a blank grievance form
24. Evidence the facility routinely monitors accidents and incidents – blank Accident/Incident Report, Monthly Tracking log and Monthly Accident/Incident Analysis
25. Current activity schedule calendar
26. Residents age 55 and under
27. Residents who communicate with non-oral communication, sign language, or who speak a language other than the dominant language
28. Medicare residents requesting a demand bill in the last 6 months
29. Administrator questions
30. Waivers or variances
31. QA Committee Members
32. Resident Council president and minutes – last 3 months
33. List of interviewable residents
34. Residents receiving hospice services
35. Hospice agreement
36. Residents receiving dialysis
37. Dialysis agreement
38. List of residents receiving TPN
39. TPN policy
40. TPN agreement
41. List of residents with negative pressure therapy
42. Wound vac / negative pressure policy
43. List of residents who self-administer medications
44. List of all employees hired within the last 4 months
45. List of CNAs
46. CLIA waiver
47. Medical Director contact information
48. Ombudsman contact information
49. TB tests
50. License verifications
51. Abuse registry checks
52. Inservice education
53. CNA annual required inservice hours
54. Infection Control team members
55. Copy of surety bond
56. Nurse Aide Training class information
57. Emergency water agreement
58. Emergency transfer / relocation agreement
59. Emergency transportation agreement
60. Influenza / Pneumococcal Immunization policy
61. Report of Resident Trust fund balances
    1. For any accounts within $200 of the SSI limit, we need evidence of notification.
    2. Discharged residents’ funds dispersed within 30 days
62. Emergency Supplies Inventory and Needs Calculation
63. Infectious waste disposal policy, contract, and last shipping record
64. Standing Orders

Obviously, if you have special programs (ie- a secure unit, mist therapy, etc.) then, have your policies and procedures related to these programs ready as well.  Add those to the list above.

I suggest going ahead and gathering these items now and updating them at least monthly until you are in your survey window.  Once in the nursing home survey window, some items will need to be updated more frequently.

You’ll notice that I put your old surveys and your old resident identifiers on the list.  You should absolutely review these and see if any certain issues keep popping up on each survey or any particular residents seemed to be selected every year.  This will help you focus on those areas and hopefully avoid repeat deficiencies.