Completing the Survey Report

2720 - Completing the Survey Report (Rev. 1, 05-21-04) 2720A - Traditional SRF (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) The Medicare/Medicaid SRF is usually a booklet that serves as a “check list” during the onsite survey to determine if the provider or supplier meets the applicable CoPs or Conditions for Coverage. These SRFs contain all of the regulations that apply to a given provider/supplier. During the survey, the provider/supplier’s conformance with every regulation in the booklet is evaluated. The SRF is still utilized in conducting surveys of most providers/suppliers, including hospices, ASCs, ESRDs, CORFs, OPTs, RHCs, and others. The various editions of the LSC are also in the SRF format. However, the traditional SRF is no longer in use on health surveys of SNF/NFs, ICFs/IID, and HHAs. (See §2720.C. and D.) The SRF for hospitals and swing-bed requirements (both CAH and hospital) are optional note-taking tools that are used at the SA or individual surveyor’s discretion. It is expected that other traditional SRFs will be phased out as survey protocols for other providers and suppliers are developed. While the SRF is still in use for most provider types, use of the Automated Survey Processing Environment (ASPEN) obviates the need for recording deficiencies on the SRF when entering findings into ASPEN through the use of laptop computers. ASPEN automatically generates an official Statement of Deficiencies and Plan of Correction (Form CMS-2567). However, the surveyor should continue to record any information on the SRF that is not being collected on Form CMS-2567. This is especially important on initial surveys and adverse actions. However, surveyors do not duplicate information that is on Form CMS-2567. Instead, surveyors cross-refer to Form CMS-2567 at the beginning of the SRF to indicate where any information that would be duplicative has been collected. Surveyors should continue to use the SRF as a checklist during surveys of those providers for which the SRF is required. If using the SRF for notes, it constitutes pre-decisional material and, like the worksheets, is not releasable under the Freedom of Information Act. Surveyors must continue to complete the various worksheets provided for the survey. It is still important to maintain accurate notes of observations to support SA findings. Where ASPEN is not used, surveyors should continue to complete the SRF in its entirety. Deficiencies and negative findings are to be explained via narrative or data under “Remarks.” Surveyors must fully document cases where enforcement action (such as termination) may ensue to substantiate the proposed action in the event of a hearing or court review, and record the status of each item at the time of the survey in the “Yes-No” or “Met-Not Met” columns, if applicable. Surveyors should use all available sources of information that will assist them in completing the SRF. If a standard or other requirement is not applicable, and therefore the “Yes-No” column is not checked, the surveyors must give an explanation. Surveyors document key areas requiring judgment by giving their reasoning, and carefully address all explanatory comments to the correct computer tag number. 2720B - Specific Items to Consider When Completing SRF (Rev. 1, 05-21-04) When using a traditional “check-list style” SRF, surveyors should support all checks in “Yes” boxes by such statements, charts, or findings as they consider appropriate (e.g., the number and type of records examined [personnel, medical], the existence and addresses of any multiple sites, special staffing information, hours of operation, the extent of compliance with related requirements). Include comments when: • The “Explanatory Statements” section on the SRF requires them; • The “Yes” or “Met” represents an apparent inconsistency with other findings. For example, two or more Requirements or Standards are marked “No,” yet the covering Standard or Condition is marked “Yes”; • A “No” has been changed to a “Yes.” (Have the change initialed and dated by the individual who made the change); or • In your judgment, additional information is needed to reflect the degree of compliance. Support “Nos” or “Not Mets” by the following: • A full description of the deficiency; • Where appropriate, charts, diagrams, and other documentation to clarify the description; • A statement regarding the degree of hazard to health and safety or the effect on the quality of care, and how the deficiency relates to other factors and standards; or • If the deficiency is significant and the covering Standard or Condition is marked “Yes,” the reasoning or judgment used in checking the “Yes.” 2720C - Completing ICF/IID Survey Report (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Form CMS-3070G-I (see Exhibit 80) is keyed to the CoPs for ICFs/IID in the Medicaid program. Surveyors use the form in conjunction with the interpretive guidelines and survey procedures for ICFs/IID (see Appendix J) to identify the regulatory requirements and corresponding tag numbers on which to assess compliance. The cover sheet (Form CMS-3070G) is the vehicle for direct data entry into OSCAR about pertinent facility, individual, and survey-related data. The first page of Form CMS-3070H, a prototype designed to be reproduced to as many pages as needed, is used to record and summarize deficiency-related data on the Standards and CoPs. The last page of Form CMS-3070H includes a certification statement for each member of the survey team to sign and date. This statement attests that each CoP-related Standard has been reviewed, and unless indicated on Form CMS-3070H, the facility is found to be in compliance. In accordance with instructions in Appendix J, surveyors complete the optional individual observation worksheet for use in conjunction with the survey. 2720D - Completing HHA and SNF/NF Survey Reports (Rev. 1, 05-21-04) The survey reports for HHAs, SNFs, and NFs are no longer the traditional “check-list style” SRFs. Rather, the HHA, SNF, and NF survey reports consist of a variety of forms and worksheets used to record information in accordance with outcome-oriented survey protocols. Surveyors complete all required forms and worksheets as instructed in the protocols.