A Survey Finding Is an Opportunity to Improve
“In long-term care, a successful survey response is not simply about correcting a deficiency identified by a state surveyor. It is about understanding why the issue occurred, addressing the underlying process failures, and establishing systems that help prevent recurrence.”
From correcting deficiencies to building systems that protect residents.
In long-term care, a successful survey response is not simply about correcting a deficiency identified by a state surveyor. It is about understanding why the issue occurred, addressing the underlying process failures, and establishing systems that help prevent recurrence.
The Centers for Medicare & Medicaid Services (CMS) requires long-term care facilities to maintain an ongoing, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. This program is intended to identify opportunities for improvement, implement corrective actions, and evaluate whether those actions are effective.
For nursing home administrators, Directors of Nursing, regional directors, owners, and other healthcare leaders, the objective is clear: correct the problem, address its underlying causes, and build systems that help prevent recurrence.
1. Address Immediate Risks to Residents
When a survey identifies a potential failure in care or facility operations, leadership must first determine whether residents are at immediate risk and take appropriate action.
Depending on the nature of the deficiency, this may include assessing affected residents, implementing protective interventions, notifying appropriate individuals, reviewing clinical records, or correcting an environmental or operational concern.
Immediate corrective action is essential, but it does not necessarily resolve the underlying system failure.
Questions for leadership to answer immediately:
Immediate Containment
Has the immediate concern been addressed safely and thoroughly?
Resident Assessment
Have potentially affected residents been identified and clinically assessed?
Protective Safeguards
Are appropriate, individualized interventions actively in place?
Reporting & Escalation
Is additional clinical follow-up, family notification, or regulatory reporting required?
2. Determine the Scope of the Problem
One identified deficiency may represent a broader process weakness.
If a surveyor identifies an issue involving one resident, leadership should consider whether the same conditions could affect other residents, departments, shifts, or processes.
For example, a missed care-plan intervention might result from an isolated documentation error. Alternatively, it could reflect a broader problem with care-plan communication, staff assignments, supervision, or competency validation.
A systematic review helps leadership distinguish between an isolated event and a pattern requiring broader corrective action.
Do not assume that a deficiency affects only the resident or department in which it was discovered. Evaluate the potential scope across all units, shifts, and staff levels before determining the full corrective response.
3. Identify the Underlying Cause
Corrective actions are more likely to be meaningful when they address why a problem occurred.
A common mistake is to respond to every deficiency with staff education alone. Training may be necessary, but it may not resolve problems caused by unclear policies, inadequate supervision, ineffective workflows, or inconsistent monitoring.
Education alone fails when the breakdown stems from contradictory departmental procedures, broken EHR handoffs, unrealistic nurse-to-resident assignments, or absence of managerial monitoring.
Re-engineers clinical workflows, clarifies cross-departmental expectations, validates staff competency in real-time, and builds recurring supervisor audits into routine practice.
Consider a facility that identifies repeated documentation deficiencies. Leadership might initially provide staff education. However, further analysis may reveal that documentation expectations differ between departments, the electronic record workflow is confusing, and supervisors do not routinely review completion rates.
In that situation, a more comprehensive response may involve clarifying procedures, improving workflow, validating staff competency, and implementing a structured audit process.
A Useful Root-Cause Review Framework
5 Core InquiriesWhen examining any operational or clinical citation, multidisciplinary teams should systematically ask:
The purpose is not simply to identify who made an error. It is to understand what the organization can change to improve reliability and protect residents.
4. Develop a Clear and Actionable Plan of Correction
A Plan of Correction (POC) should establish how the facility intends to correct a deficiency and address the factors that contributed to it.
For applicable federal nursing home surveys, facilities must follow the relevant regulatory requirements and survey-agency instructions concerning submission, correction, and compliance.
A well-developed corrective-action plan should address several core questions:
What will be corrected?
Describe the specific actions necessary to address the identified deficiency and protect affected residents immediately.
How will the facility determine whether others are affected?
Identify how the facility will evaluate the broader scope of the concern across other residents, units, and clinical programs.
What system changes will be implemented?
Explain how procedures, training, supervision, communication, or clinical monitoring will be permanently altered.
Who is responsible?
Assign responsibility to the appropriate department leader and specify the executive oversight and governance process.
How will effectiveness be evaluated?
Establish a structured monitoring and auditing process that can demonstrate whether the corrective actions are achieving sustained compliance.
CMS State Operations Manual, Appendix PP Alignment
The specific actions and deadlines must be appropriate to the deficiency and consistent with applicable requirements. CMS’s State Operations Manual, Appendix PP provides interpretive guidance for surveyors evaluating compliance with federal nursing home regulations.
A POC should not become a document that is completed, submitted, and then forgotten. Its implementation and effectiveness should remain an active part of leadership oversight.
5. Use QAPI to Measure and Sustain Improvement
Quality Assurance and Performance Improvement is not simply a meeting or a collection of audit forms. CMS describes QAPI as a systematic, comprehensive, data-driven approach to maintaining and improving nursing home safety and quality. It involves caregivers throughout the organization in identifying problems and improving processes.
An effective improvement process connects the identified problem to measurable performance.
Connecting Identified Problems to Measurable Performance
Following a deficiency (for example, involving incomplete documentation), high-performing facilities operationalize a 6-phase QAPI rhythm:
Conduct an initial audit to quantify current compliance rates.
Define explicit, measurable benchmark compliance targets.
Designate named department leads responsible for continuous monitoring.
Execute scheduled audits (daily, weekly, monthly) across shifts.
Review audit trends in weekly leadership and monthly QAPI committee meetings.
Modify interventions immediately when results do not meet benchmarks.
The facility should determine whether its actions are effective using appropriate evidence rather than relying solely on staff attendance sheets or confirmation that a new policy has been distributed.
Federal Mandate: Proving Sustained Improvement (42 CFR § 483.75)
Federal regulations require facilities to measure the success of performance-improvement actions and track performance to ensure that improvements are realized and sustained. The central question is not simply whether corrective action was completed. It is whether the evidence demonstrates that the problem has been effectively addressed and the improvement maintained.
6. Strengthen Leadership Accountability
Sustainable improvement requires clear responsibility across the organization.
The administrator, Director of Nursing, department leaders, QAPI committee, and governing body each have roles consistent with their authority and responsibilities.
Federal requirements address executive leadership’s accountability for maintaining QAPI, including during leadership and staffing transitions. They also require appropriate oversight of quality assessment, corrective action, and performance improvement.
Practical Leadership Strategies
7 Governance PillarsThese practices help make quality improvement part of the facility’s normal operating system rather than an activity that receives attention only when a survey is approaching.
7. Learn From Survey Findings Before the Next Survey
Survey readiness should be an ongoing operational priority.
Facilities can use internal audits, complaint trends, incident reports, resident and family feedback, staff observations, and performance data to identify emerging concerns.
For example, if repeated audits reveal inconsistent completion of a required process, leadership should investigate the trend before it develops into a more significant compliance or resident-care concern.
Proactive Quality Surveillance
Proactive monitoring does not guarantee a deficiency-free survey. It does, however, give leadership a structured way to identify concerns, respond to risks, and evaluate whether improvement efforts are effective before regulatory scrutiny begins.
8. A Practical Leadership Checklist
Nursing home administrators and clinical leaders can use the following checklist when managing a survey finding or other identified performance concern.
How Kay Consulting Group, LLC Supports Long-Term Care Leadership
At Kay Consulting Group, LLC, we recognize that regulatory compliance, operational stability, and quality improvement are closely connected to effective leadership.
Our firm provides interim leadership support to long-term care facilities experiencing administrator vacancies, leadership transitions, survey-related challenges, and operational needs.
Depending on the assignment’s scope, interim leadership support may include:
Our approach begins with understanding the facility’s circumstances, identifying priorities, and supporting appropriate action within the assigned role and authority.
“A survey finding should not be the end of the conversation. It should be the beginning of a structured effort to improve systems, strengthen accountability, and support better resident outcomes.”
References & Regulatory Guidance
- Centers for Medicare & Medicaid Services (CMS). QAPI Description and Background. Available at: CMS QAPI Definition & Background
- Centers for Medicare & Medicaid Services (CMS). State Operations Manual, Appendix PP: Guidance to Surveyors for Long-Term Care Facilities. Available at: CMS Appendix PP SOM Guidance
- Electronic Code of Federal Regulations. 42 CFR § 483.75: Quality Assurance and Performance Improvement. Available at: 42 CFR § 483.75 QAPI Regulation
This article is provided for general educational and informational purposes. It does not constitute legal advice, guarantee regulatory compliance, or replace review of current federal and state requirements. Facilities should consult applicable regulations, survey-agency instructions, and qualified compliance or legal professionals when responding to specific deficiencies.