How to Interpret Nursing Home Survey Reports for Dietitians

Anxious and panicky probably describe how you feel when you witness or get a call that the survey team has shown up for the annual inspection.

But have you ever wondered why you feel this anxiety and panic?

If you know that you provide excellent nutrition care and slay your other responsibilities, why worry?

For the longest time, I wondered about this too. It wasn’t until I realized that much of my anxiety and panic around surveys was because I didn’t have a good grasp on the survey process and what exactly it involved.

Once I became more familiar with the survey process and what exactly it entailed, my anxiety and panic around surveys dissipated and I became a better dietitian as a result.

To ease your anxiety and panic around nursing home surveys, here’s a detailed overview of how the process works, how to interpret the survey report, and more.

Nursing home surveys 101

Surveys are conducted to verify whether nursing homes that participate in Medicare and Medicaid programs are in compliance with state and federal regulations.

And the regulations are quite extensive. In fact, nursing homes are among the most heavily regulated industries.

These regulations are laid out in the 800-plus-page document called the State Operations Manual (SOM), which is what the surveyors use to determine whether a facility is in compliance with the requirements (1).

Surveyors don’t announce when they are coming and they are required to keep their timing unpredictable — for example, by varying the time of day, week, or month in which they come — but most nursing home surveys — called recertification or annual surveys — are completed every 12 to 15 months,

However, surveyors can also conduct surveys at other times.

For example, if a facility has been cited deficiencies or tags during a survey, the surveyors may conduct a revisit to ensure the facility corrects the deficiencies they were cited.

Surveyors can also conduct what’s called an abbreviated survey, which focuses on a specific area of concern rather than all areas that would be covered during a standard survey.

An abbreviated survey may be conducted in response to a complaint, a change in ownership, management, or the director of nursing.

The federal government contracts with your state who then carry out the surveys but a federal team may also conduct surveys.

The size of the survey team varies, depending primarily on the size of the facility being surveyed.

Nurses, dietitians, therapists, and other members of the multidisciplinary team comprise the survey team.

Most surveys last three days, but the length varies based on the facility size and the number and complexity of concerns that need to be investigated.

Therefore, a longer survey, usually, but not always, indicates that the survey team has found several issues.

The survey report (2567)

When it’s found that a nursing facility is not in compliance with the regulations, surveyors issue a deficiency or tag.

These deficiencies are reported using form 2567 — the statement of deficiencies and plan of correction.

The surveyors assign a scope and severity (SS =___ ) to each deficiency.

Scope has three levels:

• Isolated: When one or a very limited number of residents are affected, a limited number of employees are involved, and/or the situation has occurred only occasionally or in a limited number of locations.
• Pattern: When more than a limited number of residents are affected, and/or more than a very limited number of employees are involved, and/or the situation has occurred in several locations, and/or the resident(s) have been affected by repeated occurrences.
• Widespread: When the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all the facility’s residents.

Severity has four levels:

• Level 1: Has the potential for causing no more than a minor negative impact on the resident(s).
• Level 2: Has the potential for no more than minimal physical, mental, and psychosocial discomfort to the resident and has the potential to compromise the resident’s ability to maintain and/or reach his/her highest practicable well-being.
• Level 3: Results in negative outcomes that have compromised the resident’s ability to maintain and/or reach his/her highest practicable well-being.
• Level 4: Is immediate jeopardy, a situation in which immediate corrective action is necessary because the facility’s noncompliance with one or more requirements or participation has caused, or is likely to cause, serious injury, harm, or death.

(SS =__ )	Isolated	Pattern	Widespread
Level 4	J	K	L
Level 3	G	H	I
Level 2	D	E	F
Level 1	A	B	C

Bold letters within the table denote deficiency ratings that constitute substandard quality of care if the requirement that is not met is one that falls under the following regulations:

• 42 CFR 483.13 Resident behavior and facility practices.
• 42 CFR 483.15 Quality of life.
• 42 CFR 483.25 Quality of care.

Any deficiency rating in the top row of the grid for any regulation constitutes immediate jeopardy.

The tag number is cited with the letter “F” next to it with the scope and severity listed below.

The tags that primarily concern food and nutrition include F800 to F814 as well as F692 and F693.

Here are a few examples of food- and nutrition-related tags from actual surveys conducted at South Dakota nursing homes:

• F693 SS = J. Nutrition/Hydration Status Maintenance. This tag was cited because the facility failed t ensure the resident received adequate hydration.
• F803 SS = F. Menus and nutritional adequacy. This tag was cited because the kitchen failed to follow the posted menus or serve palatable food.
• F809 SS = E. Frequency of meals. This tag was cited because the kitchen failed to serve at the designated time.

Tags related to food safety and sanitation tend to be among the most commonly cited.

Learn more about food safety guidelines in nursing homes here or common food safety mistakes in nursing homes here.

What happens after the survey?

When a deficiency is cited, the survey team will decide on the appropriate action or penalty.

Depending on the deficiency and its scope and severity, the survey team may impose a civil monetary penalty (CMP) and fine the facility, which may reach tens of thousands of dollars.

A facility may also be temporarily denied payments from Medicare and Medicaid or from accepting new admissions until the issue is resolved.

In most cases, the facility will need to complete a plan of correction, explaining the steps they will take to correct the root cause of the issue.

If the surveyors issue a food- or nutrition-related tag, your administrator or executive director may ask you to assist with developing and writing the plan of correction.

Just like a nutrition intervention, your plan for correction should be aimed at identifying and resolving the root cause of the issue.

Once you establish an intervention, monitor its effectiveness and adjust as needed to ensure the problem is corrected and is no longer an issue.

You may choose to discuss the citation and the plan for correction as part of your facility’s quality assurance and performance improvement (QAPI) program.

If you believe a food- or nutrition-related tag was issued without cause, talk with your administrator, as you can dispute it through a formal process within 10 days of receiving 2567.

Depending on the citation, doing so may or may not be worth pursuing.

The bottom line

While frequently dreaded, nursing home surveys are necessary to ensure residents reach and maintain their highest quality of life.

Knowing how they work and what they involve can ease any anxiety or fear that you may have while also helping you become a better dietitian for the residents you serve.