Make sure you and your facility are prepared any upcoming state surveys with this easy-to-follow guide.
“If a facility is functioning well, it should always be ready for a survey and no preparation should be necessary. This can be accomplished by being familiar with what surveyors look for, from both a patient care and a food service standpoint, and providing that level of service 24/7.”
– Liz Friedrich, MPH, RD, CSG, LDN, FAND, NWCC, President of Friedrich Nutrition Consulting
Ensure Compliance and Excellence in Foodservice Operations
As Liz suggests, survey readiness is not about last-minute preparation, it is about maintaining high standards every day. Ensuring food safety and meeting the nutritional needs of residents and patients requires strict adherence to policies and procedures.
During state surveys, compliance is assessed using the Centers for Medicare & Medicaid Services State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev 225; Issued: 08/08/24). To maintain survey readiness at all times, food and nutrition service teams must stay informed on regulatory updates, implement best practices, and regularly assess their compliance efforts.
Understand the Regulations
A key part of maintaining compliance is understanding the regulations surveyors use to assess facilities. Begin by reviewing the CMS State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, paying close attention to the FTag information that applies to your department. Start with the F800-812 tags which cover menus, meal service, food safety, and more. You will also need to review FTags for clinical issues such as unintended weight loss, hydration, pressure injuries, documentation, and other pertinent areas.
It is also essential to review your state nursing home licensure laws. If discrepancies exist between the CMS SOM and the state licensure laws, follow the more stringent of the two regulations. Lastly, consulting the US Food and Drug Administration 2022 Food Code can provide further guidance on food safety standards.
Use Practical Tools to Assess Your Department
Conducting regular assessments helps to identify potential weaknesses and allows you to create a plan of action for improvement. To support this process, we have identified 8 key areas for survey readiness. Use this checklist for a quick review of key areas of concern in food service. To ensure your department meets standards, you can also conduct a thorough assessment using the same tools surveyors rely on, such as the CMS Kitchen/Food Service Observation form.
By prioritizing the aspects that surveyors evaluate you can proactively work towards achieving a deficiency-free survey. However maintaining compliance isn’t just about passing inspections, it requires continuous quality monitoring and improvement.
Putting it into Practice
To ensure ongoing compliance and survey readiness, directors of food and nutrition services, dietary managers, and registered dietitian nutritionists should conduct monthly internal audits using a checklist. Maintaining high standards in food service operations is essential not only for survey readiness but also for food safety, regulatory compliance, and customer satisfaction.
By implementing strict procedures, training staff, and documenting compliance efforts, your facility can create a safe and efficient food service environment ensuring both regulatory success and the highest quality of care for residents.