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One of the conditions for medical facilities to qualify for Medicare and Medicaid is to comply and maintain the federal and state regulations regarding staff and patient safety. The CMS (Centers for Medicare & Medicaid Services) is a resident-centered survey that was developed to evaluate the quality of life and care for nursing home residents. 

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Nursing homes must stay in compliance with Medicare regulations.

The CMS survey is conducted by licensed surveyors on a nationwide scale every three years at random. Failure to meet CMS standards of Medicare regulations results in hefty fines and penalizations when corrective action is needed, resulting in a loss of income for facilities whose standards fall below par. 

Once a CMS surveyor has identified the major issues within a facility, long term care consultants like Constance Woulard can, “go in and do an evaluation to help them to get their corrective action plan together, train staff, whatever they need”. Woulard, the Division Director of Nursing at Wellpath Recovery Solutions recently joined Peter Murphy LewisLTC Heroes podcast to discuss the challenges nursing facilities face, how long term care has changed, and how her role as a long term care consultant helps facilities with low ratings. 

How to Prepare for a CMS Survey

For nursing facilities, a lot rides on a successful CMS survey. Preparation for a survey includes focussing on the integrity and comprehensiveness of patient records. As hospitals move away from handwritten records and modernize to using electronic health records (EHR), patient records become more documented and organized enabling surveyors to assess the facilities level of care better.  

In recent years, the CMS’ Medicare regulations have been modified to meet updated and better practices. It is advisable to familiarize yourself with the latest Conditions of Participation (CoPs) rules in order to meet Medicare and Medicaid regulations. The new changes place emphasis on improving resident safety and reducing hospitalizations. 

Here are some tips that will get you prepared for a CMS survey: 

  1. Take Safety Seriously

Most notably, nursing facilities now receive an automatic one-star rating if there isn’t a registered nurse on-site for four or more days per quarter. For Woulard, resident safety plays a major role in why nursing facilities receive a low CMS rating and is “something that most organizations just can’t seem to keep a wrap on.” 

  1. Invest in Training

Having properly trained staff is just as important as providing a registered nurse on site. A common reason why facilities get F Tags—notifications of the violation of federal regulations—is because they do not set aside sufficient time to train nursing assistants. In the words of Woulard, “They get rushed through orientation so quickly, they throw the staff out on the floor, and they’re not prepared.”

Without adequate training, the staff will be more concerned about getting the task done than seeing the resident as a person. Therefore the human side of nursing facilities gets neglected, which impacts a resident’s quality of life. Facilities that place more emphasis on staff development tend to get better Quality Measure ratings, as they are able to maintain better care with happier residents.

  1. Stay on Top of Documentation 

During a CMS survey, nurses will be asked about resident care protocols, so you must have accurate documentation on hand. “The surveyors want specific things, such as the number of unduplicated admissions in the last twelve months,” says Cindy Firme, a Public Health Supervisor for Renville County Public Health. “They want those reports the minute they walk in the door.” 

A CMS survey will consider a facility’s documentation to make sure it is accurate.

Nurses should prepare the reports ahead of time as well as create a cheat sheet with potential questions that they might be asked during the survey. Onsite physicians will also be quizzed during a CMS survey, so have your physicians familiarize themselves with the ongoing resident care and the specifics about the resident’s medical circumstances. Organizing peer reviews will be helpful in ensuring that all staff members are prepared to know what the surveyor is looking for. This also gives the facility consistency across the team. 

Facilities should familiarize themselves with the Online Survey Certification and Reporting (OSCAR), public reports showing the results of past surveys. Woulard recommends that facilities request those and go through them. “Look at what the findings were worth,at a particular survey and work from there,” she suggested. Often you will find the five most common issues facilities face: 

  • Skin issues
  • Pressure ulcer formation
  • Hydration issues
  • Other safety issues

These may put the facility in immediate jeopardy, Woulard explained. After identifying these issues, a facility can evaluate and apply changes if necessary.

What is an F Tag?

Long term care facilities are listed under the subsection F in the federal regulations. An F Tag is when a nursing facility violates a federal regulation and Medicare regulations. There are a number of ways to ensure nursing facilities comply with regulatory standards, such as providing adequate staffing and delivering high quality of care. F Tags are revised regularly, so it is important for facilities to stay updated with the latest revisions.

F Tags are also categorized according to the degree of danger posed to the resident, from minimal harm up to high alert. The Medicare regulations for nursing homes are in place to ensure sufficient services are provided in nursing homes. The nature of F Tag penalties depends on the level of non-compliance determined during a CMS survey

A surveyor will determine whether an F Tag is an isolated incident or an ongoing issue. This is why it’s important for nursing facilities to have their physicians readily available when a survey is conducted so they can provide additional medical support if needed. 

F-Tags can also lead to litigation from residents or their families, especially when there are residents who are found to be at risk of wound care following  CMS survey results. Therefore, it is advisable for facilities to employ a specialised wound care physician to limit their chances of receiving a wound care F Tag. 

Common F Tags include:

  • F-880 – Infection Prevention and Control: This is the most common violation. It ensures residents are provided a sanitary environment with appropriate infection procedures in place. Facilities should have clear written policies with a system to record and respond to infections.
  • F-689 – Free of Accidents and Hazards: Facilities need to be mindful of foreseeable hazards by providing adequate supervision and assistance. They should conduct regular and detailed facility assessments and implement interventions when needed.
  • F-656 – Develop and Implement a Comprehensive Care Plan: Each resident has their own personalized and comprehensive care plan that states clear objectives, timeframes, and assessment criteria. Facilities need to work with qualified physicians who can map out resident care and implement the care plan. 
  • F-684 – Quality of Care: Resident care should always be focused on medical needs and patient and resident preferences. It should also include the appropriate risk factors, worsening conditions, and the psychosocial well-being of the resident.
  • F-686 (formerly F-314) – Pressure Ulcers: Pressure ulcers (bedsores) usually affect residents who are confined to bed or those who sit for long periods of time. Surveyors will look for proper documentation in residents who are at high risk of pressure ulcers. Working with a specialized wound physician can help to prevent pressure ulcers.
  • F-812 – Food Safety and Hygiene: It is important for facilities to adhere to food safety guidelines such as keeping food properly sealed and stored, abiding with expiration dates and ensuring basic food hygiene is followed. 

Receiving an F tag is detrimental to a facility, as it will affect its survey rating, which in turn will lower its reputation, consequently affecting its Medicare/Medicaid funding. Once an F Tag is issued, they are publicly visible, both on federal websites, like the site of the Department of Health, and also within the facility. This plays an important factor when families are choosing a long term care facility, as they want to know their loved one will receive appropriate care. 

What to Do Before the Medicare Regulations Survey

A nursing facility must be ready at all times for a CMS survey to check Medicare regulations. A surveyor can show up at any random time, so keeping organized and meticulous resident records with trained staff is key to impressing a surveyor. 

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Providing top-notch care and listening to residents will help prevent F Tags.

Here are some useful CMS tips facilities should do before a survey:

  1. Keep Comprehensive Resident Records for Three Months, Minimum: All resident records need to be clearly documented showing both transparency and clarity. With facilities moving towards an EHR system, records should also be consistent across all platforms and formats.       
  1. Provide Regular Staff Training: All staff members should know the requirements of a CMS assessment. Creating a survey binder with a general checklist of what a surveyor will look out for provides good staff training. Training sessions should include F Tag concerns, commonly asked survey questions, job functions, regular hours, and resident care practices. Practice answering survey questions to ensure clear and cohort answers are given during the survey. 
  1. Develop a Quality Assurance and Performance Improvement (QAPI) Program: This allows facilities to optimize and track their quality of care and quality of life for the residents. The program should be regularly updated and shown to the surveyor during the survey, so they can accurately assess the level of care provided.  
  1. Implement Regular Rounds: All staff should be familiar with residents’ care plans and conditions. By keeping organized resident records, staff can provide accurate answers when quizzed during a survey. 
  1. Hire Third-Party Consultants: Facilities can hire consultants like Woulard who will go to the facility on a monthly basis to do an audit, give advice for improvements, or focus on what is needed to pass the survey. They can also conduct “mock surveys” giving facilities the opportunity to pre-empt and fix their violations before the actual survey.

The Aftermath of a Bad Survey

When a nursing facility receives an unfavorable CMS survey, it may face penalties or hefty fines, depending on the severity of the violations. After the state surveyor files the violations, the facility must then complete their section of the CMS 2567 and submit their Plan of Correction (POC). 

It is usual practice for the POC to have input from various staff members including nurses, physicians, chief nursing officers, and members of the facility’s leadership. The POC must then be approved by the CMS in order for the facility to maintain its certification. 

The post-survey process happens in four steps:

  1. Meet the Team: Collectively, the team will review and address the concerns highlighted from the survey. Here, they will also identify the POC and analyze the preliminary report. 
  2. Prioritize the Deficiencies: The team will compare the deficiencies from the survey notes and assess the level of impact on the residents, staff, and operations. They will also evaluate the resources needed to correct and implement the actions.
  3. Develop a Timeline: The team will develop a calendar of the processes, stating which actions need to be addressed first. 
  4. Establish Accountability: The team must establish who is accountable for what. The entire staff force needs to understand why the facility received F Tags. Therefore, open communication across the team is a necessity. After all, each team member played their part in receiving the F Tags, so only collectively can the damage be repaired.  

Devising a Corrective Action Plan

The flow of command must start from the management at the top to the staff to the bottom of the chain. When devising a corrective action plan, corrections should be thoughtful with the expectation that the actions will improve the conditions in the facility. The root cause behind why the F Tag violation was given should be included in the plan of action to prevent a recurrence.

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All violations should be resolved as soon as possible with supporting evidence to help the facility prepare for their follow-up survey. For the most serious deficiencies, violations must be addressed within 45 days. It is important for all staff to know who is responsible for what within a correction plan. Therefore, careful monitoring with updated status reports is useful to track implemented changes. 


In most cases, F Tags are preventable. Take, for example, the most common F Tag, infection control. If staff are adequately trained, filling knowledge gaps, they will understand how infections are spread, so they are able to accelerate the implementation of effective actions. “The first line of defense is hand washing and cleaning the surfaces that we touch every day,” says Woulard. 

A high CMS rating is obtained through a combination of staff training, preparation, and having an understanding of state and federal regulations. It will take the combined effort of the full team to sustain and maintain high standards.  

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