Ready for Phase 3? Utilizing an Outside Partner to Increase Survey Preparedness


If you were taken by surprise by the new survey process CMS rolled out in 2017, you aren’t alone. Lots of senior living and post-acute care centers have been scrambling to comply. Many don’t even have the Phase 2 F tags that were effective last November, and even fewer are prepared for Phase 3, which begins in sixteen months. The senior living industry is constantly changing, and with the new long-term care Requirements of Participation, it can be difficult to keep up with day-to-day CMS regulations. Being ready for a state or federal survey team to walk through the door is even more challenging, but don’t throw up your hands just yet. Even if your facility is still catching up to Phase 2 requirements, don’t panic. A little outside help can increase your survey preparedness, and get you ready to embrace Phase 3 with open arms.


Utilizing outside consultants who specialize in survey preparedness and initiating lasting quality improvement measures can help. They typically start with a gap analysis to measure compliance with the CMS standards and regulations, and discuss the findings with your staff. Such outside help provides hands-on knowledge of regulations, reimbursement, rules, facility operations, and how to document to meet requirements. Consultants bring systems back into compliance quickly, and can get any center ready to meet Phase 3 head-on. If you’ve had a difficult survey already, consultants work alongside your team to develop and implement a plan of correction to resolve outstanding deficiencies, and achieve compliance quickly.


Identifying areas for improvement and drafting a plan of action is a great way to prepare for a survey, but to be truly prepared for surveyors, you’ve got to test the fences. A consulting firm can provide an early warning system with mock surveys that mirror actual federal surveys. Oftentimes, these consultants are RNs who have worked in the clinical and administrative trenches, and know exactly what tools to use to assess deficiencies, and how to maintain the survey readiness of any facility. They work on-site to pressure-test critical clinical systems, and look at core components of the nursing operation: accidents and events, skin, nutrition, and medication administration.

Performance and compliance is measured using a variety of tools. Performance is enhanced in targeted areas, risk management issues addressed, and costly deficiencies eradicated and prevented. In other words, with a little bit of practice, you can be ready for Phase 3!

Professional survey consultant services ensure a building’s survey preparedness, and gives peace of mind by knowing that your staff won’t have any surprises when the survey team walks through the door.

Teresa Remy, DSc, MHA, LNHA, BSN, RN, RAC-CT, CDP, QCP, IPCO, is the Director of Consulting at LeaderStat which provides both onsite and offsite support and training in key quality system audits, survey preparation, assistance with the development of processes that work in the real world and can be sustained, assistance with targeting areas that help prevent costly deficiencies.

Learn More About LeaderStat's Consulting Services

Contact Us

LeaderStat specializes in interim leadership, executive recruitment, travel nursing, provider recruitment and consulting for healthcare organizations.