The Nursing Home Survey Process

The Kansas Department on Aging’s Licensure, Certification and Evaluation Commission inspects, licenses, and certifies nursing homes in Kansas. Field staff document compliance with state and federal regulations through regular surveys conducted annually (at least once every nine to 15 months) and through abbreviated surveys prompted by complaints. Life safety code surveys are also conducted by the Kansas State Fire Marshal’s office.

The survey process involves on-site evaluations – always unannounced – of the care and services provided to residents in accordance with regulatory requirements. In the case of Medicare and Medicaid certified facilities, the standards are set by the Centers for Medicare and Medicaid Services (CMS).

During surveys, deficiencies may be cited if the facility fails to meet any of the requirements.

Each deficiency cited is assigned a scope and severity level (from A to L), which indicates the level of harm and the pervasiveness of the deficient practice. Level A means no actual harm and an isolated basis, while L means immediate jeopardy to resident health and safety on a widespread basis.

The following chart shows the various levels:

Level	Scope	Severity
A	Isolated	No actual harm, potential for minimal harm
B	Pattern	No actual harm, potential for minimal harm
C	Widespread	No actual harm, potential for minimal harm
D	Isolated	No actual harm, potential for more than minimal harm, that is not immediate jeopardy
E	Pattern	No actual harm, potential for more than minimal harm, that is not immediate jeopardy
F	Widespread	No actual harm, potential for more than minimal harm, that is not immediate jeopardy
G	Isolated	Actual harm that is not immediate jeopardy
H	Pattern	Actual harm that is not immediate jeopardy
I	Widespread	Actual harm that is not immediate jeopardy
J	Isolated	Immediate jeopardy to resident health or safety
K	Pattern	Immediate jeopardy to resident health or safety
L	Widespread	Immediate jeopardy to resident health or safety

About the three levels of scope:

• An isolated problem means one of a very limited number of residents are affected.
• A pattern of problems means more than a limited number of residents are affected or the same problem has occurred in several locations in the facility and/or the same number of residents have been affected by repeated occurrence of the deficient practice.
• Widespread scope means the problems causing the deficiencies are found throughout the facility and/or there are systemic failures in the nursing home that have affected or have the potential to affect a large proportion of the residents.

About the four levels of severity:

• Level 1 represents no actual harm, but has the potential for minimal harm
• Level 2 represents no actual harm, but has the potential for more than minimal harm. A level 2 deficiency could result in minimal physical, mental or psychosocial discomfort or has the ability to compromise the resident’s ability to maintain or achieve highest possible function.
• Level 3 represents actual harm that is not immediate jeopardy (i.e., life-threatening). Level 3 means a resident has been negatively impacted and his or her ability to maintain or reach the highest functional level has been compromised.
• Level 4 represents immediate jeopardy to resident health or safety. Level 4 requires immediate corrective action because serious injury, harm, impairment or death has been caused or could be caused to residents.

Deficiencies are cited at the highest severity level. If a deficient practice has minimal impact on most affected residents, but has a severe impact on only one, that deficiency will be cited at the highest severity level observed.

When there are deficiencies, certified facilities have 10 days to respond with a Plan of Correction. KDOA staff reviews the plan. If the plan is acceptable, the survey staff makes a revisit to verify that corrections have been made.

Penalties can be imposed in the case of more serious deficiencies. In Medicare/Medicaid facilities, that can be a civil monetary penalty and/or a denial of new Medicare/Medicaid payment for admissions.

Both state and federal regulations require facilities to post results of the most recent survey in a place readily accessible to residents.