Loading

The Nursing Home Survey Process

The Kansas Department for Aging and Disability Services (KDADS) Survey, Certification and Credentialing Commission inspects, licenses, and certifies nursing homes in Kansas. Field staff document compliance with state and federal regulations through regular surveys conducted annually (at least once every nine to 15 months) and through abbreviated surveys prompted by complaints. Life safety code surveys are also conducted by the Kansas State Fire Marshal’s office.

The survey process involves on-site evaluations – always unannounced – of the care and services provided to residents in accordance with regulatory requirements. In the case of Medicare and Medicaid certified facilities, the standards are set by the Centers for Medicare and Medicaid Services (CMS).

During surveys, deficiencies may be cited if the facility fails to meet any of the requirements.

Each deficiency cited is assigned a scope and severity level (from A to L), which indicates the level of harm and the pervasiveness of the deficient practice. Level A means no actual harm and an isolated basis, while L means immediate jeopardy to resident health and safety on a widespread basis.

The following chart shows the various levels:

Level Scope Severity
A Isolated No actual harm, potential for minimal harm
B

Pattern

No actual harm, potential for minimal harm
C Widespread No actual harm, potential for minimal harm
D Isolated No actual harm, potential for more than minimal harm, that is not immediate jeopardy
E Pattern No actual harm, potential for more than minimal harm, that is not immediate jeopardy
F Widespread No actual harm, potential for more than minimal harm, that is not immediate jeopardy
G Isolated Actual harm that is not immediate jeopardy
H Pattern Actual harm that is not immediate jeopardy
I Widespread Actual harm that is not immediate jeopardy
J Isolated Immediate jeopardy to resident health or safety
K Pattern Immediate jeopardy to resident health or safety
L Widespread Immediate jeopardy to resident health or safety

About the three levels of scope:

About the four levels of severity:

Deficiencies are cited at the highest severity level. If a deficient practice has minimal impact on most affected residents, but has a severe impact on only one, that deficiency will be cited at the highest severity level observed.

When there are deficiencies, certified facilities have 10 days to respond with a Plan of Correction. KDADS staff reviews the plan. If the plan is acceptable, the survey staff makes a revisit to verify that corrections have been made.

Penalties can be imposed in the case of more serious deficiencies. In Medicare/Medicaid facilities, that can be a civil monetary penalty and/or a denial of new Medicare/Medicaid payment for admissions.

Both state and federal regulations require facilities to post results of the most recent survey in a place readily accessible to residents.

| KDADS Disclaimer | Kansas Open Records | KDADS Privacy Statement |
| Kansas.gov Home Page | Contact KDADS |
Page Last Updated: February 4, 2014