The Centers for Medicare & Medicaid Services (CMS) makes periodic updates to the Long-Term Care Survey Process materials. The most current version is dated 6/19/2021. Ensure you have the current information, including the Entrance Conference Form, Matrix and Critical Element Pathways – they may not all be the same since the LTCSP was implemented. You can always locate the most current materials on the CMS Nursing Homes webpage.
Helpful Tips:
- Not sure where to check? The date on the forms is in the bottom left hand corner of each document.
- You can also keep track of changes by looking at the Revision History for LTC Survey Process Documents and Files to see what was changed with each update.
Here are many of the updated forms contained in the .zip file of Survey Resources via the CMS webpage.
| Form | Document Link |
| Entrance Conference Form Focused Infection Control Survey Entrance Conference Form | Entrance Conference Form (6/2021) FICS Entrance Form (6/2021) |
| Matrix for Providers | CMS 802 (11/2020) |
| List of Revised F-tags | List of Revised Ftags (6/2021) |
| SNF Beneficiary Protection Review | Form CMS-20052 Beneficiary Notice (1/2018) |
| Dining Observation | Form CMS-20053 Dining Observation (1/2018) |
| Infection Prevention, Control & Immunizations | Form CMS-20054 Infection Prevention Control and Immunization (6/2021) |
| Kitchen Observation | Form CMS-20055 Kitchen (5/2017) |
| Medication Administration Observation | Form CMS-20056 Med Admin (11/2017) |
| Resident Council Interview | Form CMS-20057 Resident Council (12/2017) |
| Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan Review | Form CMS-20058 Quality Assessment and Assurance Review (2/2017) |
| Abuse Critical Element Pathway | Form CMS-20059 Abuse (5/2017) |
| Environmental Observations | Form CMS-20061 Environment (11/2017) |
| Sufficient and Competent Nurse Staffing Review | Form CMS-20062 Sufficient Nursing Staff Pathway (1/2018) |
| Personal Funds Review | Form CMS-20063 Personal Funds (2/2017) |
| Activities Critical Element Pathway | Form CMS-20065 Activities (5/2017) |
| Activities of Daily Living (ADL) Critical Element Pathway | Form CMS-20066 Activities of Daily Living (5/2017) |
| Behavioral and Emotional Status Critical Element Pathway | Form CMS-20067 Behavioral-Emotional (2/2017) |
| Urinary Catheter or Urinary Tract Infection Critical Element Pathway | Form CMS-20068 Urinary Catheter or UTI (5/2017) |
| Communication and Sensory Problems (Includes Hearing and Vision) Critical Element Pathway | Form CMS-20069 Comm-Sensory (5/2017) |
| Dental Status and Services Critical Element Pathway | Form CMS-20070 Dental (11/2017) |
| Dialysis Critical Element Pathway | Form CMS 20071 Dialysis (5/2017) |
| General Critical Element Pathway | Form CMS-20072 General (2/2017) |
| Hospice and End of Life Care and Services Critical Element Pathway | Form CMS-20073 Hospice and End of Life (5/2017) |
| Death Critical Element Pathway | Form CMS-20074 Death (1/2018) |
| Nutrition Critical Element Pathway | Form CMS-20075 Nutrition (5/2017) |
| Pain Recognition and Management Critical Element Pathway | Form CMS-20076 Pain Mgt (5/2017) |
| Physical Restraints Critical Element Pathway | Form CMS-20077 Physical Restraints (5/2017) |
| Pressure Ulcer/Injury Critical Element Pathway | Form CMS-20078 Pressure Ulcer (5/2017) |
| Specialized Rehabilitative or Restorative Services Critical Element Pathway | Form CMS-20080 Rehab and Restorative (5/2017) |
| Respiratory Care Critical Element Pathway | Form CMS-20081 Respiratory Care (7/2018) |
| Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway | Form CMS-20082 Unnecessary Medications (5/2017) |
| Medication Storage and Labeling | Form CMS-20089 Medication Storage (2/2017) |
| Preadmission Screening and Resident Review Critical Element Pathway | Form CMS-20090 PASARR (5/2017) |
| Extended Survey | Form CMS-20091 Extended Survey (1/2018) |
| Hydration Critical Element Pathway | Form CMS-20092 Hydration (5/2017) |
| Tube Feeding Status Critical Element Pathway | Form CMS-20093 Tube Feeding (5/2017) |
| Positioning, Mobility & Range of Motion (ROM) Critical Element Pathway | Form CMS-20120 Positioning, Mobility, ROM (1/2018) |
| Hospitalization Critical Element Pathway | Form CMS-20123 Hospitalization (11/2017) |
| Bladder or Bowel Incontinence Critical Element Pathway | Form CMS-20125 Bladder and Bowel Incontinence (11/2017) |
| Accidents Critical Element Pathway | Form CMS-20127 Accidents (5/2017) |
| Neglect Critical Element Pathway | Form CMS-20130 Neglect (5/2017) |
| Resident Assessment Critical Element Pathway | Form CMS-20131 Resident Assessment (5/2017) |
| Discharge Critical Element Pathway | Form CMS-20132 Discharge (11/2017) |
| Dementia Care Critical Element Pathway | Form CMS-20133 Dementia Care (5/2017) |
| Focused Infection Control Survey Protocol | Survey – COVID-19 FIC Survey Protocol 6/21 |
Survey Consulting Assistance
Whether your organization is preparing for survey or needs help with regulatory response (such as a Plan of Correction, Directed Plan of Correction or Directed In-Service), CMSCG’s interdisciplinary team of compliance and quality improvement consultants can help. Contact us to learn more about how we can work together.
To learn more about CMS Compliance Group’s consulting services for skilled nursing facilities, click here.
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