Survey for Recertification

7203.3 - Survey for Recertification (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) Follow the procedures specified in the LTCSP Procedure Guide for standard and extended surveys. The Standard Survey is a periodic, resident-centered inspection which gathers information about the quality of service furnished in a facility to determine compliance with requirements for participation. The survey is outcome-oriented and relies on a case- mix stratified sample of residents. Outcomes include both actual and potential negative outcomes, as well as failure of a facility to help each resident achieve and maintain their highest practicable level of well-being. General Survey Policy: Follow procedures detailed in the LTCSP procedure guide to conduct the recertification survey. Key components of the survey process include conducting observations, interviews, and record reviews including reviewing for the accuracy of the residents’ comprehensive assessment. This section contains CMS guidance and policy related to conducting the standard survey. Resident Privacy: The survey team must conduct the survey in a manner that allows for the greatest degree of confidentiality for residents, particularly regarding the information gathered during the interviews. Use the resident identifier (e.g., a code number assigned to each resident in the resident sample) on the Form CMS-2567 in place of the resident’s name, which should never be used on the Form CMS-2567. When observing residents, respect their right to privacy, including the privacy of their bodies. If the resident’s genital, rectal area, or breast area must be observed in order to document and confirm suspicions of a care problem, a member of the nursing staff must be present at this observation, and the resident must give clear consent. If the resident is unable to give consent, e.g., is unresponsive, incompetent, and a health care proxy who can act on the resident’s behalf or legal representative (as provided by State law) is available, ask this individual for consent. An observation of a resident’s rectal, genital or breast area may be made without a resident’s or legal representative’s consent, under the following conditions: • It is determined that there is a strong possibility that the resident is receiving less than adequate care, which can only be confirmed by direct observation; • The resident is unable to give clear consent; and • A legal representative is not immediately accessible. Basic Principles of Using Photography During the Survey 1 Although the use of photography during the survey process is not required, the State Survey Agencies (SAs) may decide to collect photographic evidence to support a finding of noncompliance. The SA will be responsible for the acquisition, accountability, and security of the photography equipment (e.g., smart phone, camera) and data/images. Additionally, the SA should develop guidance for using photography during the survey process and train staff in the proper use of the camera. States should ensure that all photos are maintained in accordance with all applicable privacy and confidentiality laws and policies. Surveyors may use photography as a tool, supplementing written documentation, to assure accurate and effective records of observations made during surveys with the intent to produce photographs that are relevant to possible deficiencies. However, without written documentation, photographs cannot stand alone. Photographs may enhance findings of noncompliance by providing visual evidence of injury, scene, or other relevant components of a deficient practice. Photographs should not be included as part of the Form CMS-2567. Surveyors should only reference photographs in their surveyor notes and not in the statement of deficiencies. When taking photographs during a survey, the following basic principles should be implemented: 1. Request the Resident’s or His/her Representative’s Written Permission Prior to Photographing His/her • Before beginning, ask the individual’s written permission to take a photograph, to the maximum extent feasible. • The health and dignity of the individual is always a paramount concern. A surveyor should respect an individual’s refusal to be photographed. • If the individual’s genital, rectal, or breast area is photographed in order to document and confirm suspicions of care problems, a member of the nursing staff must be present at the time of observation, and the individual must be asked to give written consent before the photograph may be taken. 1 Some material included in this guidance is from the Illinois Department of Public Health, Division of Long-Term Care Field Operations, “Guidelines for Photographic Evidence.” • If the individual is unable to give consent (e.g., is unresponsive, incompetent), and the individual’s legal representative is present, ask the representative for written consent, unless the representative is the one suspected of abusing the individual. • If the individual is unable to give consent and the individual’s representative is not present in the facility, then the surveyor may use discretion in determining whether a photograph of the individual’s rectal, genital or breast area is necessary to support a finding of noncompliance. • Surveyors should avoid taking pictures that will reveal an individual’s face or other uniquely identifying information that will interfere with that person’s right to privacy. 2. Get a Complete Series of Photographs Generally, each relevant object in the scene should appear in at least three photographs: an overview, a mid- range photograph, and a close-up. • Because a close-up does not indicate where the object was located, the overview photograph should cover the entire scene to bring out the relationships between the objects. Leave measuring scales and labels out of the overview photograph. • The mid-range photograph shows a relevant object and its immediate surroundings. • Each close-up photograph shows a key detail clearly. Have a “standard” in the close-up photograph to indicate the actual size of what is being photographed. - Measure scales and labels may be added to the close-up photograph. For example, placing a ruler with readable graduations next to a pressure ulcer will show its actual size in the photograph. - Other standards include tape measures, coins, or a pencil. 3. Documentation and Storage of Photographs A surveyor must handle a photograph of the individual with as much confidentiality as a medical record. Only non-personal identifiers should be used to document the photograph. A reference in the surveyor notes should be made of each photograph even if it did not portray the expected image so there will be a sequential reference to all photographs taken. In addition to proper documentation, photographs depicting residents must be stored properly. This means that any photographs taken to support deficient practice must contain non-personal identifiers and then be attached to the survey when uploaded to the survey software. Photographs must only be shared with those having a need to know, such as survey managers, SA officials, HHS Office of the General Counsel, or others as appropriate. When sharing photographs, it is imperative that secure or encrypted email is used, and proper chain of custody must be maintained. Chain of custody as defined by the National Institute of Standards and Technology, is a process that tracks the movement of evidence through its collection, safeguarding, and analysis lifecycle by documenting each person who handled the evidence, the date/time it was collected or transferred, and the purpose for the transfer. Immediately upon taking a photograph, document in surveyor notes the following: • Date; • Time; • The identity of the photographer; • A photograph identifying number (even if just one photograph is taken); • Facility name; • Survey event number, as applicable; and • Non-personal identifier. Note: Many conventional cameras and digital cameras have the capacity to imprint a date and time on the photographic image. Do not modify an original photograph. A surveyor who wants to stress a key detail in a photograph should identify the detail by using a transparent overlay that can be removed to show the unaltered print. Examples of Photographic Evidence: • Evidence of abuse, such as contusions, bruises, lacerations, or burns • Evidence of improper and dangerous use of restraints or other devices • Evidence of improper positioning such as leaning, or hypo- or hyper-extension of neck and/or trunk • Pressure ulcers • Contractures • Safety hazards • Evidence of extensive pest infestation • Evidence of faulty or dirty equipment Confidentiality of Survey Materials Surveyor notes and documentation collected during the survey process contain pre- decisional information and therefore, are not required to be disclosed to the facility at the time of the survey. If providers or other stakeholders are requesting additional information, they need to submit that request following the appropriate federal and state laws and/or processes for disclosure. The survey team should maintain an open and ongoing dialogue with the facility throughout the survey process. This gives the facility the opportunity to provide additional information in considering any alternative explanations before making deficiency determinations. This, however, does not mean that a daily exit conference is held with the facility, or every negative observation is reported to the facility on a daily basis. Moreover, if the negative observation relates to a routine that needs to be monitored over time to determine whether a deficiency exists, the survey team should wait until a trend has been established before notifying the facility of the problem. Identification of Past Non-Compliance Citations: Findings cited as past noncompliance (PNC) may be identified during any survey of a nursing home. See additional information on PNC at 7510.1. For PNC to exist, the following criteria must be met: • The facility was not in compliance with the specific regulatory requirement(s) (as referenced by the specific F-tag or K-tag) at the time the situation occurred; • The noncompliance occurred after the exit date of the last standard (recertification) survey and before the survey (standard, complaint investigation, or revisit) currently being conducted; and • There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance at the time of the current survey for the specific regulatory requirement(s), as referenced by the specific F-tag. When a citation of PNC is written, the facility does not provide a plan of correction as the deficiency is already corrected; however, the survey team documents the facility’s corrective actions on Form CMS-2567. (Additional information about citations of PNC is found at 7510.1 – Determining Citations of Past Noncompliance at the Time of the Current Survey)