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 Pennsylvania Department of Health Nursing Care Facilities Survey Understanding Survey Results - Scope and Severity
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Nursing homes are commonly referred to as nursing care facilities or long-term care facilities. The Pennsylvania Department of Health inspects nursing homes every twelve to fifteen months. If they have a history of serious problems or complaints are received, they may be inspected more frequently. All nursing homes must have a license to operate in Pennsylvania. Inspections of nursing homes are called surveys. The Department of Health surveys nursing homes to make sure they are following state licensure regulations and federal regulations (rules). The federal regulations apply when nursing homes choose to receive reimbursement for their residents' stay from the Medicare and/or Medicaid Programs. During a nursing home survey, deficiencies (non-compliance with regulations) are identified. The department staff members, also known as surveyors, write an official report of their observations and record them on a form called the CMS 2567. For every deficiency that is identified, the surveyors must decide how serious the problem is for the residents. "Scope and severity" determination is made during every certification inspection. It reflects both how serious and how often a problem occurs in the nursing home. The surveyors write a description of the problems, which is then called a "Statement of Deficiencies". A copy of the report is sent to the nursing home requiring that a plan to fix the problems be submitted. The nursing home must submit in writing their proposed solutions to the identified problems, this is called a "Plan of Correction". You can ask to see a copy of this report at any nursing home. Nursing homes must have notices posted to tell you where the survey results are kept. Or you can view these reports on the Department of Health web site. When you look at the CMS 2567, or a Statement of Deficiencies, please keep in mind that it only tells you what was observed on the dates of the survey. It is simply a snapshot of what life in the nursing home was observed to be like by the surveyors during that time frame. Since that date, conditions in the nursing home could have changed. Also, keep in mind that if deficiencies observed during a survey result in sanctions affecting the nursing home's license or its participation in the Medicare and/or Medicaid Programs, the nursing home has the right to appeal those sanctions through an administrative appeal process. If the facility wins its challenge of the sanctions imposed, the CMS 2567 may change as a result. Even if there are no sanctions imposed, a nursing home may disagree with the findings of the surveyors by including a response on the CMS 2567 averring facts that rebut or refute the factual findings relied upon by the Department to support a deficiency. Therefore, while reviewing survey results is a good beginning in determining the quality of a nursing home, it should not be the only way you judge a facility. Touring the nursing home, talking to the Area Agency on Aging Ombudsman, discussing the home with community professionals and hearing the experiences of residents and their families are all important ways to evaluate a nursing home. When you select a nursing home to review from our map of Pennsylvania and then select a specific survey to review for that nursing home, you will notice several things. First, this is a slightly modified version of the CMS 2567 but it includes the same information as the CMS 2567. Also, the Statement of Deficiencies is broken down into separate sections for each regulatory deficiency identified during that survey. Each of these sections contains general information at the top followed by two main columns. At the top of each section, the regulation identifies the specific federal or state regulation which the facility was violating during the survey. Reference may also be made to other relevant regulations that could be used in citing the particular area of non-compliance. Also at the top of each section is a bar graph that identifies the severity of the deficiency and how many people it affected. The left-hand column for each section includes (from top to bottom), the observations completed by the surveyors, the findings of the surveyors, and the Pennsylvania Code numbers for all of the other state regulations that were violated by the observed behavior or events. The left-hand column contains the information from which the nursing home and public can understand how the surveyors reached their conclusions as to the violated regulations. The portion identified as observations describes the process by which a surveyor gathered the relevant information contained in this Statement of Deficiencies and is written by the surveyor who made the observations. The portion of the left-hand column headed findings provides detailed factual findings that identify the deficient practice. This is done to assist the nursing home in identifying when and where the deficient practice was observed and, as appropriate, the duration of each observation. Essentially, the findings section describes the specific results and consequences of the nursing home's deficient practice for the individual cases reported in the findings. The findings portion is also written by a surveyor. The Pa. Code numbers at the bottom of the left column refer to the additional State Licensure regulations that are violated by the facts contained in the findings portion of the left-hand column. In the right-hand column, you will find a section entitled "Plan of Correction - To be completed: Date." This section is written by the nursing home and tells you what steps they will take to correct the regulatory deficiency identified in the left-hand column and the date they expect to have the problem corrected. The right-hand column will also include facts that the nursing home has alleged to rebut or refute the factual findings supporting the Department's determinations contained in the findings portion of the left-hand column. Last modified on 02/24/05 |