Kathy left a comment with some questions that I am going to address in my post today, instead of in the comments. She has some valid questions, and I hope this will help Kathy, as well as anyone else with the same concern, understand why a nursing home and hospital surveyor asks the questions they do and what any facility, whether nursing home or hospital, can do to help reduce restraints. You can see Kathy’s comment at the post titled “Surveying Restraint Regulations in Hospitals or Nursing Homes – Part I“.

Hi Kathy,

CMS doesn’t look for a “diagnosis”, but for the MEDICAL reasons for a restraint. The interpretive guidelines at the restraint regulations in Appendix PP of the SOM (State Operations Manual) gives a lot of guidance and additional thoughts on what you might consider. Every nursing home should have a copy of the SOM. In addition, activities will be a huge help for you. When a person is participating in activities, that keeps them busy, but, of course, activities that that person would be interested in. That is where your investigative and creative skills come in with each resident. What interests him or her?

Also ask, WHY is the resident getting up? What does he or she want to do? What is the pattern? Is it all the time or at specific times? Does he or she need to use the bathroom, or perhaps the resident is hungry, or bored. Is the chair comfortable or is the resident so uncomfortable he or she has to get up (we all know how uncomfortable some chairs can be). What did the person do as a career? Is that why he or she is getting up. Is he or she looking for something specific to do? Maybe the resident worked the night shift and is used to staying up all night and sleeping in the afternoon. These are just a few of the questions you can consider to help you figure out how to keep the resident safe while at the same time keeping the resident as free from restraints as possible. Perhaps your resident just needs someone with him or her all the time to interact, provide companionship, and stimulating conversation (whether or not the resident can respond).

I would also suggest you network with other nursing homes (I’m assuming you are working in a nursing home) and gather ideas and information about what works for them, how their activities departments help and how they keep residents with dementia safe while allowing them to walk. A resident who walks is going to be maintaining stronger muscles and better walking ability than one who is forced to sit in a chair all day.

There is no pat answer to the regulations and how to stay in compliance. Each situation requires its own determination of what will work. That is one of the great challenges and opportunities that nursing home staff have. This is also one area that nursing home and hospital surveyors will continue to review and question.


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After the nursing home survey team has finished with the survey, the members will then write the issues they found. This writing is done on the “Statement of Deficiencies”, commonly referred to as the “2567”. The number “2567” refers to the number CMS has assigned to the statement of deficiencies form.
The statement of deficiencies is written in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met. This is when the team will also make a final determination of the level of Severity and Scope. You can refer to my previous post on “The A to L of Nursing Homes” to understand a little more about how surveyors grade a nursing home.
So that is just a little bit about how a nursing home surveyor prepares to conduct a nursing home survey and the tasks they must perform during the course of the survey.
Now you must remember that because of the process of sample selection, the nursing home survey team does not look at every resident or patient in a nursing home or hospital. Because of this, there are many times that problems within a nursing home or hospital are not found. This is where it becomes so important for you, the public healthcare consumer, report the problems you find to the local licensing & certification agency who conducts these surveys. You are, in essence, a second set of eyes to help the survey agency know where to look and who to ask. Even then, though, it can become quite difficult to “prove” anything. It is becoming frequently more common for nursing homes and hospitals to challenge the findings from a survey. If the nursing home team does not have all the information to show the failure to follow the regulation the deficiency can be “thrown out”. So when you do report your complaints to a survey agency, give them as much information you can, including names, dates, specific times, actions, etc. The more you can tell them the better the nursing home surveyors chances are in substantiating your complaint.

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I discussed with you a bit about the Tasks one expects to see a nursing home surveyor conduct during a “QIS” nursing home survey. Those tasks are different than those conducted in a traditional nursing home survey. A nursing home surveyor will have 7 tasks in a traditional survey.

Task 1: Offsite Survey Preparation. This is where the nursing home survey team identifies issues that might be seen based on their review of documents that include the previous survey, the facility’s history of survey compliance and a review of the facility’s complaint history. During this time the team will also gather information from a database to compare the facility to others in the state and the nation. Concerns of the ombudsman are also reviewed. There may also be issues the team is aware of such a news reports, lawsuits and such. This information is also reviewed prior to the survey to help identify issues that need reviewed during the survey. During this time the team may decide they need specialty surveyors to attend the survey.

Task 2: Entrance Conference/Onsite Preparatory Activities. During this time the team coordinator informs the facility’s administrator about the survey and introduces team members. The rest of the team then begins Task 3 (The initial tour) while the team coordinator talks with the Administrator and gathers additional information. The SOM requires the team coordinator get specific information during the time of this entrance conference.

Task 3: The Initial Tour. During this time the nursing home surveyor gathers information about concerns which have been pre-selected; new concerns discovered onsite; and whether residents pre-selected for the Phase 1 sample offsite are still present in the facility. The surveyors will attempt to meet and talk with as many residents as possible. The nursing home surveyors can do the tour by themselves or accompanied by facility staff.

Task 4: Sample Selection. During this task, which occurs after the initial tour, the nursing home survey team will finalize the issues and the sample of residents that they will concentrate on during the first phase (Phase I) of the nursing home survey. Most of the time the team will continue to use the set of residents they selected during the off-site preparation, but there are times when they will substitute other residents. The SOM gives the survey team specific instructions on how and why to do this.

The Phase 2 sample is selected after the team has completed most of the Phase 1 investigations and reviews. At this point the nursing home survey team has collected enough information to determine what areas they need to focus on during the rest of the survey.

Task 5: Information Gathering. This is often considered the “meat” of the survey. The instructions given to the nursing home surveyors on conducting information gathering provides an organized, systematic, and consistent method of gathering information necessary to make decisions concerning whether the facility has met their requirements. Task 5 is divided up into 7 “subtasks”. These subtasks are:

  • 5A General Observations of the Facility
  • 5B Kitchen/Food Service Observations
  • 5C Resident Review: An overall assessment of the sampled residents
  • 5D Quality of Life Assessment: Assessment of the residents’ quality of life
  • 5E Medication Pass and Pharmacy Services: An assessment of the pharmaceutical services provided in the facility
  • 5F Quality Assessment and Assurance Review: An assessment of the facility’s Quality Assessment and Assurance program
  • 5G Abuse Prohibition Review: A review of the facility’s policies and procedures related to protecting residents from abuse, neglect, involuntary seclusion, and misappropriation of their property.

Task 6: Information Analysis for Deficiency Determination. This is the step in which the nursing home surveyors gather all the information they have obtained and they then meet together and review their findings. The nursing home survey team determines if the nursing facility has met or has not met all the regulatory requirements

Task 7 – Exit Conference. This tsk is to inform the facility of the survey team’s observations and preliminary findings.

Just becasue these tasks are  numbered doesn’t mean they all ocurr in an order. The ones at the beginning and end do, but the ones in the middle are all conducted pretty much simultaneously and continuously during the survey.

We will continue this in the next post.

Keep safe and informed!


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I am in the midst of explaining some concepts to you about how a nursing home surveyor prepares to conduct a nursing home survey. This is Part 3. I talked a little about the two forms of Survey, the QIS survey and the Standard survey. I want to explain, now, the Tasks for the QIS nursing home survey that the nursing home surveyors must do.

The QIS Tasks are:

  • Task 1: Offsite Survey Preparation. This includes an initial resident sample selection. During this task the nursing home surveyors also review files, previous complaints and surveys, and other information in order to be familiar with the issues the nursing home survey team might encounter while at the nursing home.
  • Task 2: Onsite Preparatory Activities and Entrance Conference. This is where the nursing home survey team lets the facility know what to expect during the survey. The team gathers additional paperwork and nursing facility information and continues to develop the plan for the survey.
  • Task 3: The Initial Tour. Upon entering a nursing facility the nursing home surveyors do a tour of the facility prior to commencing with the investigative portion of the survey. This is different than a Hospital survey in that hospital surveys do not have an initial tour.
  • Task 4: Stage I Survey Tasks. These include finalizing the sample selection, conducting nursing home survey team meetings, gathering information, reviewing records, and interviewing staff, residents, and families.
  • Task 5: Non-Staged Survey Tasks. This includes more interviews, reviews of policies and procedures, Abuse Prohibition review, Quality Assessment and Assurance review, observation of the food services, and reviews of billing.
  • Task 6: Transition From Stage I to Stage II. During this stage of the QIS process the nursing home survey team updates the resident sample, reviews what was found in Stage I, puts data into the laptop and reviews the analysis of the findings (the QCI’s mentioned previously)
  • Task 7: Stage II Survey Tasks. This is again composed of more sampled resident reviews, team meetings, more investigation, observation of the Medication administration, Environmental observations, reviews of resident funds, reviews of admission, transfer and discharge issues, and facility staffing.
  • Task 8: Analysis and Decision-Making. This is where all the information is integrated and analyzed in order to determine what areas are non compliant.
  • Task 9: Exit Conference. This is where the nursing home surveyor and the team provide information about their preliminary findings to the nursing home.

In the next post we will continue with the process a Nursing Home and Hospital Surveyor follows when conducting a nursing home survey.

Keep informed and keep safe!


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