Preparing with PIPs: Strengthening Your Survey Readiness
Originally published in NADONA’s The Director Quarterly Journal, Spring 2025 Issue.
Over the past few months, we have all become aware of CMS Memo – QSO-25-07-NH – Revised Long-Term Care (LTC) Surveyor Guidance, which includes significant revisions to enhance the quality and oversight of the LTC survey process. With the effective date now pushed to April 28 (QSO-25-14-NH), surveyors continue to learn the revised guidance and prepare for upcoming surveys. In addition to these revisions, many facilities face increasingly complex surveys that span several years of review.
CMS has also announced the reinstatement of the Internet Quality Improvement and Evaluation System (iQIES) – Revised: Training Plan for iQIES Launch in Long-Term Care, beginning July 14. Unlocking data within the electronic health record (EHR) and working through Quality Assurance and Performance Improvement (QAPI) programs may be key to achieving successful survey outcomes. Performance Improvement Plans (PIPs) help facilities proactively address deficiencies identified during internal audits, providing a structured framework for improvement and documentation.
F685 clearly defines the regulatory guidance: “§483.75(a) Quality assurance and performance improvement (QAPI) program. Each LTC facility, including a facility that is part of a multiunit chain, must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.”
In addition to the design and scope: “A facility must design its QAPI program to be ongoing, comprehensive, and to address the full range of care and services provided by the facility. It must:
- 483.75(b)(1) Address all systems of care and management practices;
- 483.75(b)(2) Include clinical care, quality of life, and resident choice;
- 483.75(b)(3) Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a SNF or NF.”
Successful survey preparation requires a multifactorial approach with true interdisciplinary involvement, including input from residents and family members. Facilities should review citations from the past three years, including complaints, grievances, and reportable events, to identify areas needing improvement. Facility and company culture play a crucial role in determining how objectively audits are conducted and how willing staff members are to report concerns, errors, or areas of increased risk.
While reviewing CASPER reports is important, other factors influencing quality of care must be considered. Predictive views of quality measures, changes in resident conditions, rehospitalization trends, and infection development provide valuable insights. Routine audits of high-risk areas – such as falls, abuse, elopement, and high-risk medications – are critical in maintaining quality and safety.
Technology and data within EHRs offer access to multiple sources for monitoring care and systems, but relying solely on retrospective data may not be enough for proactive quality improvement. Solutions that provide real-time, interventional analytics empower facilities to identify and address risks before they lead to citations or adverse outcomes. By proactively monitoring resident conditions, predicting potential declines, and intervening at critical moments, interventional analytics solutions – such as Real Time – bridge the gap between data collection and actionable improvements in quality of care.
Unlike static reports that offer only a historical view, real-time data analytics provide immediate visibility into quality measures, compliance risks, and potential deficiencies. This proactive approach enhances survey readiness, improve clinical and operational decisions, and streamlines preparations. In addition to comprehensive reviews, targeted efforts should focus on identifying areas for improvement, including root cause analyses of specific issues. PIPs support systemic improvements by outlining tasks, goals, responsibilities, and timelines, fostering a proactive culture. This structured approach not only helps identify and correct issues but also enables facilities to present their efforts to surveyors and support any cited deficiencies.
Incorporating the QAPI process and corresponding PIPs into survey preparedness efforts reduces citations, minimizes plans of correction, and most importantly, improves the quality of care and outcomes for residents. Leveraging real-time interventional analytics empowers facilities to go beyond historical data, enabling immediate, informed decisions that enhance resident care and operational efficiency.
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About the Author
Cheryl Scalzo, RN | Customer Success Manager | Real Time Medical Systems
A former Director of Nursing, Cheryl Scalzo has dedicated her career to improving quality of care. While working in long-term care and as a Clinical Consultant, she has served as a Certified Infection Preventionist and staff development coordinator, gaining extensive knowledge in establishing and implementing best practices to improve quality outcomes. Cheryl currently shares her expertise with Real Time clients, guiding them in unlocking the power of EHR data to improve clinical performance.