This week’s “Ftag of the Week” on the CMSCG Blog is part of the Resident Rights regulatory group, F577 Right to Survey Results/ Advocate Agency Info. The requirements for this regulation are not complex, but they lend themselves to an easy “gotcha” citation because there are multiple opportunities for a surveyor to identify that current survey results are not accessible to a facility’s residents. First, let’s look at the regulatory requirements, and then, we’ll look at some actual survey citations to give you an idea of where a facility can get tripped up in the process.
Access to Survey Results
Residents in a nursing facility have the right to review the results of the facility’s most recent survey, as well as any associated plan of correction for identified deficient practices. The facility is required to post the most current survey results in a place that is readily accessible to residents and their representatives. “Readily accessible” means that the information is available to interested parties without their having to request it from the facility for review.
Providers are also expected to retain the results of any surveys, including complaint investigations, that occurred during the previous three years, as well as the associated plans of correction for issues identified. This information must be made available to any individual who wishes to review it upon his/ her request. A notice that this information is available must be posted in prominent locations and areas accessible to the public.
The facility is prohibited from altering the survey results in any way, and is also required to ensure that identifying information about residents or complainants is not available. That means do not post the Resident Roster that accompanies your survey results. Think that this doesn’t happen? It does!
The facility is prohibited from altering the survey results in any way, and is also required to ensure that identifying information about residents or complainants is not available. That means do not post the Resident Roster that accompanies your survey results. Think that this doesn’t happen? It does!
Advocate Agency Info
F577 also requires the facility to have in place procedures to ensure residents can receive information from advocacy agencies and are provided with the opportunity to contact such agencies if they desire to do so.
Here are some examples of how F577 has been cited on survey:
Standard Survey S/S: C
Surveyors reviewed ASPEN to identify the surveys conducted at a facility, and found multiple conducted throughout 2020. The surveyor reviewed the facility’s survey results available to residents and found that the survey binder had not been updated since 2019, and also included survey results from an affiliated sister facility of the provider. The Administrator stated during interview that the survey results for the current year were located only on the first floor, including the results of a complaint investigation impacting a first floor resident. This information was not accessible to residents on other floors.
Standard Survey S/S: D
During observation, a surveyor identified that the facility’s survey results book was located on the second shelf in a resident lounge. The height of the shelf made it impossible for a resident in a wheelchair to reach the book if he/she wanted. The surveyor interviewed a wheelchair-bound resident in the lounge and asked the resident if he/she wanted to see the survey results. The resident had to request assistance in retrieving the book.
Standard Survey S/S: F
During observation, a surveyor noticed that the facility’s survey findings were inside of an enclosed bulletin board. The bulletin board case would not slide open, and so the survey results were not accessible except for the first page. Another survey book was identified in the lobby, but the information was not current. During a Resident Council interview, the surveyor asked the residents if they knew where the survey results were, or if they were allowed to review them without asking for permission. All residents stated that they did not know where the results were kept or if they were available for their review without request. It was further noted in an interview with the Administrator that the posted survey data was not readily accessible to wheelchair-bound residents since the bulletin board was not accessible at wheelchair level and that it was difficult to open the case.
While there are many citations for F577 with a Scope/Severity of “B” or “C,” there are also many that are cited at a widespread S/S of “F.” Citations such as these are easily avoidable – double check your facility’s practices. Consider posting on each unit at wheelchair level a notice as to where the survey results are located. A reminder during Resident Council meetings of where the survey binder is located also only takes a few seconds. For whatever reason, survey binders or part of the contents are sometimes known to “disappear” – assign a staff member the responsibility for making sure the survey binder is in the correct location for resident and or visitor review and that all of the survey documents that are supposed to be available for review are in the binder.
