‘Guilty Until Proven Innocent’: How Nursing Homes Are Navigating a Tough Survey Environment

As operators face a difficult survey environment, collaborating with other industry leaders – and trying to work with state survey agencies – may be the key to staying in the green.

“As providers, I think it’s really easy for us to concentrate solely on our company,”  Kimberly Green, COO of Diakonos Group, said during a recent Skilled Nursing News (SNN) panel on the skilled nursing survey environment. “When we all realize that there are enough patients to go around and that the industry is changing, we must all collaborate with each other. Here, we want state agencies to collaborate … we really need to see each other as peers and work together.”

In discussing how to improve the survey process so that it’s more collaborative and productive for all involved, Green was joined by Tim Fields, CEO at Ignite Medical Resorts, and Sonya Pusser, AVP of Clinical Operations at American Health Communities. The panelists highlighted examples of undeserved and avoidable citations, and suggested that those involved with surveys return to using some of the practices, including educational opportunities, of the pre-Pandemic era.


Diakonos recounted a specific incident where her team challenged a survey finding all the way to the federal level, and the frustration her team experienced when surveyors seemed uninterested in reviewing documentation and partnering with providers.

“We are waiting to hear about that,” she said. “But when we were trying to talk to the surveyor about it, and show them what was in the documentation, they basically refused to even review it. It was like, ‘This is what it is, we’re moving on, you can deal with this,’ because Immediate Jeopardy has a very specific process.”

Pusser echoed Green’s sentiments, citing instances of regulatory misinterpretations leading to undeserved citations, despite her teams’ efforts to address compliance issues promptly.


“We find some of that in one of the smaller [regulations] that has come to mind,” she said. “There’s the regulation related to labeling and storage; well, it really just speaks to those medications that are going to expire before the manufacturer expiration date. But then they’ll come in and cite all these different medications that really do expire at the expiration date.”

Yet she said that there are opportunities for improvement in communication and collaboration between health care associations, such as the Health Care Association and the American Health Care Association, and regulatory bodies like the Health Commission, who can work on behalf of providers to share insights and feedback, aiming for more timely surveys, results, and follow-ups.

She said that before the pandemic, operators in Tennessee had an educational forum on an annual basis where operators and surveyors could ask each other questions.

“I think there are opportunities out there; we just have to get back to doing that,” she said. “And they have to be willing to remember what it was like. I think it’s helpful if the surveyors have some long-term care experience to gain insight into what it’s like in a long-term care facility.”

Regional variability

Regional variability in survey approaches across different states is something that Ignite has to keep track of, Fields said, since they operate in Wisconsin, Illinois, Indiana, Missouri, Kansas, Oklahoma, and Texas.

“We’re seeing a form of [variability] in every single state,” he said. “Again, I’m painting with a broad brush here on some really good surveyors out there. There are some really good regents out there. Some people have been very collaborative and fair to work with; some of our higher-ups, you know, contacts at all the state levels, have been great to work with.”

Such friendships with other multi-state operators, and amicable relationships with surveyors, can help operators get a leg-up on potential areas of concern, Pusser said.

“Where elopement might have been an immediate jeopardy years ago in one state, it’s not now…It does seem to change as you move along,” she said. “We do have some great surveyors who have that experience and really do want to offer you assistance. They can’t give you recommendations, but sometimes, if you respond quickly to certain things and they know you’re going to address it, you might get that FYI.”

The panelists agreed on the importance of establishing proactive communication channels with survey agencies, fostering mutual understanding, and working towards shared goals of enhancing resident care.

Regular communication and collaboration between providers and state agencies proved beneficial, especially during the pandemic, Green said.

“The state would have weekly phone calls, and all the providers would get on,” she said. “They would roll out any new regulations, any changes, clarify for understanding, and ask if we had any input…Now, I have to admit, initially, it was a running joke because it was basically [state officials] were saying, ‘I don’t know, I don’t know, I don’t know,’ to most of our questions. But it turned into a really great Q&A where we learned together.”

Education opportunities for staff

Fields recommended utilizing the entire management team to address patient and family concerns before they escalate to state involvement. He also advocated for a concierge or hospitality model to engage families directly and resolve issues internally, rather than having them escalate to state authorities.

“We have to play in an environment where we’re guilty until proven innocent,” he said. “And if we take that mindset and try to play offense on this, there are a lot of things we can do on a daily basis.”

Ignite has implemented ‘Guardian rounds,’ where the entire management team checks up on patients and families to make sure there aren’t any issues, Fields said.

“I’ve heard from many state representatives that if they get called, they can only come in once a year,” he said. “So, they’re not coming in for an annual visit; they’re coming because somebody called them. Preventing people from calling them is a good way to play offense.”

Pusser recommended attending educational sessions, developing policies and procedures, and consistently educating facility staff.

“Come up with your internal plan on how you are going to make adjustments within your education, policies, procedures, and electronic health records (EHR) to be able to answer all the questions with the updated Minimum Data Set (MDS),” she said.

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