The Survey Process is Changing - Will You Be Ready: Handouts/Q&A

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare



The following links contain the handouts and materials used for this webinar.  Click to download this information for future use.

The Survey Process is Changing – Will You Be Ready? PowerPoint Slides

F-Tag Crosswalk

Federal Regulatory Groups (F-Tags)


A few questions were asked during the webinar.  Here are my answers:

QUESTION: What are the limitations of surveyors after exit for requesting additional information; we had requests 5 additional days upon exit.

ANSWER: That’s a great question.  My recommendation is that you pose that question to the NH Survey Development mailbox at:   


QUESTIONS: Can you provide a link for the CD Pathways?  and Where can we get a copy of the CE Pathways?

ANSWER: The line to the current 41 current Critical Element Pathways is:


QUESTION: Did I read that some congressional members have requested a delay in implementing this year’s new requirements due to undue financial hardship?

ANSWER:You heard correctly. You can read more about this at More than 100 lawmakers urge CMS to rethink long-term care requirements (October 13, 2017 – McKnight’s Long-Term Care News).


QUESTION: When will the surveyor guidance forms be updated on the CMS website?

ANSWER: I believe you’re referencing the CE Pathways.  They were recently updated and are found at:  If you need additional information, email the NH Survey Development mailbox at:


QUESTION: Is this only for (LTC) facility? Or all the home care?

ANSWER: The information presented in this webinar relates only to long-term care facilities.


QUESTION: If our facility is non smoking and we have a non smoking policy is that against any resident rights if they have been informed of it prior to admission?

ANSWER: It is not as long as you inform the resident/resident representative prior to and at the time of admission.  Be sure they are aware of your policy before admission for full disclosure and to avoid issues after admission.


QUESTION: Will this cut down on cross tags?

ANSWER: Great question. I think that time will tell.  I do view the new F-Tags as being more specific but circumstances of the non-compliance issue could warrant cross tags.  You could also pose that question to the NH Survey Development mailbox at:


QUESTION: New req for crushed medications.  Have you seen this and your thoughts.

ANSWER: I have seen that new guidance in the June 30, 2017 version of Appendix PP.  It falls beneath F760 - The facility must ensure that its residents are free of any significant medication errors. §483.45(f)(2).  Here’s what that guidance says in respect to crushing meds (found on page 502):

The standard of practice is that crushed medications should not be combined and given all at once, either orally (e.g., in pudding or other similar food) or via feeding tube. Crushing and combining medications may result in physical and chemical incompatibilities leading to an altered therapeutic response, or cause feeding tube occlusions when the medications are administered via feeding tube. Additionally, a resident may not want or may be unable to finish eating the food into which combined crushed medications were added or the resident’s feeding tube could malfunction, all of which could prevent complete administration of the crushed medications. In these situations, staff would not know which medications the resident actually received because they were crushed and combined but not fully administered.

If the surveyor observes medications being crushed and combined, then the number of errors would be equal to the number of medications crushed whether the medications are to be administered orally or via feeding tube. For example, if four medications were crushed and added altogether to applesauce or combined to be administered all at once via feeding tube, then four errors have occurred before the medications have been administered.

This guidance also says (at the top of page 502):


The crushing of tablets or capsules for which the manufacturer instructs to “do not crush” requires further investigation by the surveyor. Some exceptions to the “Do Not Crush” instruction include:

  1. If the prescriber orders a medication to be crushed which the manufacturer states should not be crushed, the prescriber or the pharmacist must explain, in the clinical record, why crushing the medication will not adversely affect the resident. Additionally, the pharmacist should inform the facility staff to observe for pertinent adverse effects.
  2. If the facility can provide literature from the medication manufacturer or from a peer-reviewed health journal to justify why modification of the dosage form will not compromise resident care.


The above guidance speaks to crushing meds and giving orally as well as via feeding tube. I think it’s good practice to not combine crushed meds and give all at once.  If the resident does not finish the food or other substance such as applesauce that contains all the crushed medications, how will the clinician determine what was given and what was not.  Giving crushed medications all at once via a feeding tube speaks to the “bolus” of medications that can occlude the tube.  While combining everything all at once may seem efficient, it is not accepted practice and will certainly net the clinician with one or more deficiencies. 

I also recommend referencing the guidance regarding crushing medications that a manufacturer says Do Not Crush, particularly the justifying documentation required when this is ordered.



©2009 Briggs Healthcare