Variance in Timing (Time of Day, Day of Week, Time of

7207.2.2 - Variance in Timing (Time of Day, Day of Week, Time of Month) (Rev. 244; Issued: 06-26-26; Effective: 06-26-26; Implementation: 06-26-26) (Refer to the LTCSP Procedure Guide for additional off-hour guidance.) When facilities are surveyed, the day of the week and time of month should be varied from the time of the previous standard survey. The month in which a survey begins should not, if possible, coincide with the month in which the previous standard survey was conducted. At least 10 percent of standard health surveys must be conducted as off-hour surveys. These off-hour surveys are aimed at providing better insight into how a facility is staffed and operates outside of business hours, as well as reducing the predictability of when a survey will occur. Off-hour surveys begin either on the weekend or before 6:00 a.m. or after 5:00 p.m. on weekdays. When entering a facility during residents’ routine sleeping hours, surveyors are to proceed with survey activities while also respecting the residents’ need for sleep. During off-hour surveys, the team coordinator (TC) is to complete the Entrance Conference with the designated person in charge and then conduct a follow-up Entrance Conference with the administrator, as needed, upon his/her arrival at the facility. The survey team should not wait for the resident roster or matrices to begin screening residents. Additionally, the survey team that has entered the facility during off-hours should be alert to situations that might indicate concerns with the following: • sufficient staff; • infection control; • medication errors; • compliance with medication storage; • abuse/neglect; • pain management; • behavioral health; • restraints; • accidents/hazards/smoking; and • environment. While concerns with compliance in these areas may exist during normal business hours, survey teams may gain a more realistic view of facility activities during the early morning or late evening time of day. During off-hour surveys, modify the Initial Pool Process as necessary to accommodate the residents’ activities occurring at the time of entry. Surveyors must respect residents’ need for sleep, by taking care not to be intrusive or wake the resident. Observations of the resident and the room may be made, but interview status may have to wait until the resident is awake. If residents are found to be awake, surveyors should introduce themselves. Members of the survey team may be able to start some facility level tasks that wouldn’t disturb residents (e.g., sufficient and competent staffing, medication storage, kitchen, medication administration observation, infection control). Additionally, a minimum of 50 percent of the 10 percent of off-hour standard health surveys must begin on a weekend day (Saturday or Sunday). Facilities for weekend surveys must be selected using the list provided by CMS. State Agencies may do more than a minimum of 50 percent. Survey time on holidays can be counted toward the 10 percent of off-hour surveys to be conducted .“Holidays” are defined as those days that are recognized by the State as a State or Federal holiday. NOTE: If the survey is commencing during off-hours (before 6:00 a.m. or after 5:00 p.m. or on a Saturday or Sunday), once onsite, announce the survey, ascertain who is in charge, ask the person to notify the administrator that a survey has begun. Conduct Step 12 in the LTCSP Procedure Guide with the designated person in charge and complete the task and the onsite preparatory activity as appropriate within the context of the survey. Conduct a follow-up Entrance Conference with the administrator, as needed upon his/her arrival at the facility. All standard health surveys, including those conducted to satisfy the 10 percent off-hours requirement, must be conducted with the survey team onsite for a minimum of two consecutive calendar days after entrance. Consecutive calendar days include Saturdays, Sundays, and Holidays. For example, a survey that begins at 8:00 a.m. on a Friday morning must be continued for two consecutive calendar days.