Consumer Guide: Provider Search Survey History Information

Staff at DQA complete all surveys. These staff are called surveyors. Surveyors do the survey at the provider facility, in person.

A survey can take place for many reasons:

• To recertify or renew a facility's license. This is called a standard survey.
• To make sure a provider has fixed any issues found in a past survey. This is called a verification (follow-up) visit survey.
• To look at a complaint or incident. This is called an investigation visit survey.

Most providers don't know when a surveyor will come to complete a survey. How often surveys happen depends on the provider type. State license laws and federal requirements define when surveys take place. Other factors can impact when surveys are needed too. For example, a provider might have more surveys if there are complaints, or they've had bad survey results in the past.

During a survey, the surveyor sees if a provider is following state license laws and/or federal Medicare and Medicaid rules. The surveyor notes any violations of laws or requirements on a Statement of Deficiency (SOD) form (CMS-2567) (PDF). They may also require the provider to turn in a written Plan of Correction (POC). In this form, the provider comes up with a plan to fix each violation.

For registered (not certified) residential care apartment complexes, surveys only happen if there's a complaint. If the surveyor finds problems, they issue a Notice of Non-Compliance letter instead of an SOD form.

The Regulation of Health and Residential Care Providers web page includes specific state rules and federal regulations for each provider type. There are also survey guides based on provider type. These offer more details about the survey process:

• Assisted Living Survey Guide
• Survey Guide: Adult Day Care Centers, P-03495 (PDF)
• Survey Guide: Behavioral Health Certification for Mental Health and Substance Abuse Services, P-63174 (PDF)
• Survey Guide - Facilities Serving People with Developmental Disabilities, P-63051 (PDF)
• Survey Guide Home Health and Hospice Licensure and Certification, P-63075 (PDF)
• Survey Guide - Hospitals and Other Health Services Providers, P-62033 (PDF)
• Survey Guide - Long-Term Care Facilities, P-62014 (PDF)
• Survey Guide - Personal Care Agency Approval, P-00191
• Survey Guide Clinical Laboratories - Clinical Laboratory Improvement Amendments (CLIA), P-01227 (PDF) and Interpretive Guidelines for Laboratories - Appendix C

The Survey Type tells you why a surveyor completed the survey. You may be able to find more details in the initial comments of the SOD.

Many provider types require a Health survey and a Life Safety Code (LSC) survey. During the LSC survey, an engineer or architect surveyor sees if the provider meets life safety code requirements from the National Fire Protection Association. The LSC survey includes many fire protection and safety aspects.

These provider types require LSC surveys:

• Ambulatory surgical centers
• End stage renal disease treatment facilities
• Facilities for people with developmental disabilities or intermediate care facilities for individuals who are intellectually disabled
• Hospice agencies
• Hospitals
• Nursing homes

For these provider types, the Survey Type says either Health survey or Life Safety Code survey. It also includes a reason for the survey.

Some surveys last for days. The Exit Date tells you the last day of the survey.

Enforcement includes actions or penalties (also called remedies) for the provider. They may apply to the provider based on how serious their deficiency/violation is or how long it takes them to fix it. If a provider gets a penalty, you'll see a document under Enforcement.

DQA issues actions or penalties for providers licensed through the state. CMS (Centers for Medicare & Medicaid Services) issues final actions or penalties for providers that are part of Medicare and/or Medicaid.

The type of provider impacts what penalties they get. Examples include:

• Getting a state monitor.
• Completing in-service training.
• Not getting paid for new patients.
• Paying fees.

If a provider doesn't correct deficiencies, they may also be removed from Medicare/Medicaid or closed.

Surveyors list survey findings in an SOD form (CMS-2567) (PDF). You'll find a link to the SOD in this part of the Survey History. The link labels the SOD as either State or Federal.

A deficiency is something that goes against a state or federal regulation. It's also called a violation. Surveyors note deficiencies and reasons for the deficiency in the SOD.

• The top of each SOD page includes details about the provider: identification number, provider name, and provider address.
• The top-right shows the Exit Date (when the survey was complete).
• The (X4) ID Prefix Tag column includes a tag code specific to the deficiency. There's also a tag code for initial comments, which comes first on each SOD. Initial comments explain the need for the survey and may include a summary of findings.

One survey may involve more than one SOD. Surveys with tags that relate to the state have separate SODs from surveys with tags that relate to federal regulations. LSC deficiencies also have their own SOD. These relate to the physical condition of the property.

Nursing homes only - Federal deficiencies

For all federal deficiencies at nursing homes only, surveyors must rate how serious the deficiency is for people who live in the nursing home. This is called assigning scope and severity (SS). Tag codes use SS and a letter in the (X4) ID Prefix Tag column to define the deficiency.

Nursing homes and facilities serving people with developmental disabilities only - State deficiencies

Any state deficiencies noted at nursing homes or facilities serving people with developmental disabilities (also called intermediate care facilities for individuals with intellectual disabilities) are listed as class violations:

• Class A - Violation of a state code creating "a substantial probability that death or serious mental or physical harm to a resident will result therefrom."
• Class B - Violation of state code "directly threatening to the health, safety, or welfare of a resident."
• Class C - Violation of a state code that "does not directly threaten the health, safety or welfare of a resident." A Class C violation is issued if the same code was cited within the past 24 months or if an Order to Correct was not corrected at the verification visit.
• Correction Order - Order to Correct: A Class C level violation that was not cited in the past 24 months.

If a surveyor finds a deficiency, the provider often must submit a Plan of Correction (POC). The plan describes the action the provider will take to fix each deficiency and the date they'll complete it. It also explains how they'll keep up with regulations going forward.

The provider notes the POC in either the SOD or POC, F-00344.

You'll find a link to the POC in the Plan of Correction part of the Survey History. The link labels the POC as either State or Federal. If the survey results in no violations, it's noted in Provider Search.

Assisted living facilities only

In the past, the Bureau of Assisted Living required assisted living facilities to submit a POC with any violations listed on an SOD after a survey. As of October 1, 2020, assisted living facilities no longer must submit a POC when they get an SOD. This applies to all SODs that result from state violations.

The assisted living facility still should have an internal system in place to prevent deficiencies and respond to the SOD. The surveyor may offer help and suggest an internal system that answers:

• What action and system changes will happen to make sure deficiencies are fixed, now and in the future?
• Who is in charge of making sure the provider keeps up with regulations?
• What date will each corrective action happen?
• What internal quality improvement processes could help find and fix any future compliance issues?

The Bureau can still request a POC as needed.

Certified Residential Care Apartment Complexes that get an SOD with violations don't submit a POC. Instead, they submit an Attestation of Correction, F-02172. On the form, the provider promises to correct any deficiencies within 45 days of the SOD notice. The provider must return the completed form to DQA.