Night Hawk

CMS survey inspections are a rigorous process, and the outcomes can dramatically impact a facility’s star rating. While high-level deficiencies grab headlines, many facilities struggle with common pitfalls that quietly erode their scores and increase financial penalties. Two recurring themes consistently emerge: a critical lack of comprehensive documentation and the absence of a detailed plan of correction.

When an annual survey is completed, a complaint is filed, or a deficiency is noted, the ability to provide clear, accurate, and timely documentation is important. This isn’t just about ticking boxes; it’s about providing an irrefutable account of the care provided and the preventative measures in place.

The Documentation Dilemma

Consider the sheer volume of incidents that occur in senior living – especially falls. A staggering 95% of falls are unwitnessed, making it incredibly challenging for staff to complete the required incident reports with the necessary detail. Without precise information on date, time, circumstances, and immediate actions, reports become vague, opening the door to scrutiny and potential penalties. Surveyors are looking for evidence of thorough investigation and follow-up, and missing details undermine your ability to demonstrate effective care.

Imagine reviewing an incident report for an unwitnessed fall. How can you accurately assess the cause or the resident’s state without knowing their position, surrounding environment, or what they were attempting to do just before? This lack of granular detail is a red flag for surveyors and increases the chances of a financial penalty and a lower star rating.

The Missing Plan of Correction

Beyond documenting the incident itself, facilities are expected to present a robust “Plan of Correction” (PoC) for every deficiency noted. This isn’t a formality; it’s a strategic document outlining specific actions, timelines, and responsible parties to address each issue and prevent recurrence. When a facility lacks a detailed, well-executed PoC, it’s a clear indication to CMS that the underlying problems may not be genuinely resolved, escalating a minor deficiency into a larger, more persistent problem. This can significantly impact the final survey results and star rating.

Accurate and complete documentation is the backbone of defensible care and successful CMS surveys. It’s the evidence that demonstrates your facility’s commitment to quality and compliance. It’s good to understand how crucial these ratings are for your facility’s reputation and financial health. In part 3 of this blog series, we’ll explore how advanced technology can bridge these critical documentation gaps, providing the precise, real-time data needed to fortify your facility against deficiencies and proactively elevate resident care.