For facilities selected for a Risk-Based Survey (RBS), the entrance conference looks significantly different from the standard survey process. The RBS Entrance Conference Worksheet contains only 14 required items compared with 40 on the standard Entrance Conference Worksheet. Facilities should be familiar with both processes so staff can quickly recognize which worksheet applies and, importantly, the different timelines for providing requested information.
For an RBS, the facility must provide three items immediately upon entrance: the census, an alphabetical list of all residents noting anyone currently out of the facility, and the name of the staff member responsible for the Infection Prevention and Control Program. The survey team will then conduct a brief Entrance Conference with the Administrator. The Administrator is asked to notify both the Medical Director and Resident Council President that the survey is underway and that they have an opportunity to provide input to the survey team.
One of the most important differences in the RBS process is the one-hour deadline. Within one hour of entrance, the facility must provide the medication administration schedule, actual working schedules for all staff separated by department, key personnel information, the completed CMS-802 for all residents, EHR access for each surveyor, and QAA committee information.
For smaller facilities with 1–30 beds, the RBS worksheet also directs the facility to immediately identify residents who meet specific categories: a fall with major injury within the last 120 days; a current Stage 3, 4, or unstageable pressure ulcer not present on admission; tube feeding with weight loss or dehydration within the last 180 days; current dialysis, hospice, or ventilator use; and current facility-acquired transmission-based precautions with the infection identified.
LeadingAge Ohio members who have experienced an RBS have shared that information moves to the survey team much more quickly than during the standard survey process, making readiness and timely access to requested information especially important to a successful survey outcome.