BSC LTC Stakeholder Webinar Recap (SNF)

The Bureau of Survey & Certification’s (BSC) January 2024 LTC Stakeholders Webinar covered information and guidance related to the use of Attestation in Lieu of Revisit surveys, more commonly known as Desk Reviews (DR). David Donahue, Long Term Care Division Director, shared that Revisit surveys soon would begin using EGRESS for document uploads, with onsite visits starting first and DRs to follow shortly after. Additional guidance and tips for DR submissions were shared that are intended to speed the review process as well as ensure providers have submitted the documents required to complete the reviews without additional requests:

• Read your Notification Letter thoroughly as it contains language regarding eligibility for a DR as well as guidance on how to submit.
• When submitting documents, if labeled to coordinate with the respective F-tag and/or element of the Plan of Correction (POC) it speeds up the review process.
• When sharing documents related to education provided as part of the POC, include what was taught (PowerPoint slides if available) and who was taught. BSC requests that providers print a list of employees who signed up to attend and have employees sign in next to their printed name. That way one document lists who was planning to attend and who actually attended.
• Audit tools should include all elements being monitored.
• If an Audit does not demonstrate compliance, include comments on actions or additional measures taken to move to full compliance.

Facility Reported Incidents (FRI) were also discussed with a couple of tips for success. CMS now requires state agencies to prioritize FRIs for investigative surveys based on the initial report filed. BSC is required to prioritize the need for an onsite visit if unable to determine that actions were taken to ensure the affected residents’ safety. Including documentation of the steps taken to ensure safety in the initial report allows for lower prioritization of the FRI. In the follow-up 5 Day Report, inclusion of sufficient information to describe the investigative process, any corrective actions taken if applicable, and any updates or changes to the initially reported information all provide information useful towards assigning a desk review status to a FRI. 

Slides and recordings of this meeting, along with previous meeting resources, are available.