Education News

Is Your Community Ready for Its Next Recertification Survey?

Here’s What You Need to Know

Q2, June 2025

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Recertification surveys are an important opportunity to show the strength of your operations and the quality of care your team provides every day. While preparing for a visit from the Executive Office of Aging & Independence (AGE) may feel stressful, it doesn’t have to be. With the right preparation and a few key focus areas, your community can feel confident and ready.

Between January 3 and April 3, 2025, AGE conducted 23 site visits in Massachusetts assisted living communities. Of these, 19 were standard recertification surveys and 4 were related to complaints. The average number of findings per visit was 15, with some visits showing as few as 3 and others as many as 36. Even more notable—an average of 6 repeat findings were cited per visit. This tells us that while communities may be addressing issues, some areas still need more consistent follow-up.

So, what can your team do now to prepare for your next survey?

1. Be Ready from the Moment They Walk In

Surveyors will expect your team to provide a quick update upon arrival, and more importantly, they’ll want to see that all required information is organized, easy to access, and audit-ready. This includes resident records, incident reports, service plans, assessments, and communication logs. If your community has strong systems in place and staff know where to find what’s needed, you’re already ahead of the game.

2. Focus on the Areas Most Often Cited

The most frequent findings from the recent quarter’s surveys can help guide your internal :

• Quality Assurance/Quality Improvement (QA/QI): Cited in 91% of visits
• Incident Reporting: Cited in 91% of visits
• E-call Systems: Cited in 63% of visits
• Service Plans: Cited in 63% of visits
• Assessments: Cited in 54% of visits
• Communication Logs: Cited in 54% of visits

Knowing where citations tend to occur gives you a head start on strengthening your documentation and practices.

3. Double-Check Your QA/QI Program

Make sure your QA/QI efforts are more than just checkboxes. Surveyors often found missing documentation around service plan reviews, safety audits, and medication reviews. Also, ensure your program is identifying risks and making real improvements—especially around medication administration (SAMM/LMA), which was a common concern.

4. Strengthen Your Incident Reporting Process

Timeliness and completeness are key. Surveyors cited communities for late submissions and reports missing information that staff already knew. Make sure your team knows what needs to be reported and how quickly it needs to be documented. 5. Test and Monitor E-call Systems Regularly

Surveyors are looking closely at e-call system response times. Many citations came from response times that exceeded community policy, or from inconsistent monitoring and testing. Review your policies and make sure you’re documenting regular tests and follow-ups.

6. Review Service Plans and Assessments for Accuracy

Check for outdated information, conflicting details, or missing updates. Signatures matter too—make sure you’re documenting any efforts to obtain them from residents or responsible parties. This shows you’re following through, even if the signature isn’t ultimately obtained.

7. Make Your Communication Logs Count

Surveyors want to see continuity between shifts. Notes like “shift was quiet” aren’t enough. Encourage your staff to document key events such as falls, medical leaves (MLOA), behaviors, and anything that triggered an incident report. This isn’t just about compliance—it also improves resident care and handoffs between team members.

Take Action Now—Not the Week Before a Survey

Surveys may feel unpredictable, but being ready isn’t out of reach. Start with a mock audit, focus on high-risk areas, and build strong internal systems for documentation and follow-up. Involve your whole team in the process—when everyone understands their role, it’s much easier to stay on track.

Recertification surveys are your community’s chance to show the quality work you’re already doing. With thoughtful preparation and attention to detail, your team can approach your next visit with confidence and pride.

To support your readiness efforts, Mass-ALA offers ongoing training and resources throughout the year. Don’t miss our Mass-ALA Boot Camp sessions on September 16 and November 18. The November Boot Camp is part of our NEW Compliance Series Training, designed to help communities stay proactive and informed in the areas of compliance with QA/QI, Safety Meetings and Survey Readiness.

We also encourage you to stay connected through upcoming calls:

• Mass-ALA Member Connections Virtual Meeting August 27
• Executive Office of Aging & Independence (AGE) Quarterly Call on July 16 (the certification team emails the link to their email list in advance of the meeting)

In addition, we send out to gather data from visits conducted by the Ombudsman, AGE, and OSHA. These insights help us identify trends and tailor our training to address real-time challenges, while also keeping members informed with timely updates and practical guidance. Attend a Mass-ALA Member Connections meeting or our upcoming Regulations Training on June 12 for trends and insights we gather through the monthly questionnaire.