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Focus Topic: Top 15 Highly Scored Standards
We’re continuing our review series on the Top 15 Most Cited Clinical Standards in survey preparation. Last week, we concluded the top five that ended with a discussion on informed consent.
This week we're turning our attention to Pain, Care Plans, Assessment and Reassessment, H&P’s and Pre-Anesthesia Assessments and related patient care standards.
So, we're all on the same page, this is 6, 7, 8, 9, 10 of the top 15 frequently cited standards. Next week, we'll cover 11, 12, 13, 14, and 15. If you've been following our newsletter, then you would have received 1 through 5 last Sunday.
PC.01.02.07 EP 7 — Reassess and Respond to Pain
(NPG 06.02.01 EP 7; SPG Page 606)
This element of performance and CMS CoP is a long-standing, frequently cited topic dating back to 2001 when TJC published its first pain management standards. CMS surveyors view effective pain management, assessments, and reassessments as a patient right in addition to citations landing with nursing, quality, and leadership.
Common Findings:
- Missed or Late Pain Reassessments: In most cases, the patient’s health record will show evidence that pain reassessments often weren’t completed or documented within the required timeframe after pain medication, whether oral or IV. Many policies require reassessment between 30 minutes and one to two hours post-administration.
- Pain Scores: Some records lacked pain scores, reassessment times, or follow-up details, making it difficult to verify compliance. For example, if a patient scored a pain level of seven, and the hospital policy required that characteristics of pain be evaluated as part of the assessment, then the lack of required descriptors (location, duration, radiating, quality, etc.) would be cited as part of this standard and element of performance. Likewise, with a CMS surveyor, practice follows policy. With CMS, it could be scored as a patient right.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
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Not typically a condition level deficiency, but it will be scored in the TJC matrix as either low or moderate risk, depending on what the surveyor finds or how thoroughly they “pull the thread.” The survey process is the same, with different standard numbers.
- To avoid incurring another finding in pain management, consider conducting proactive patient health record audits to ensure compliance with pain reassessment standards. A finding in this standard will require an audit in the evidence of standards compliance response, so I have always found it a better strategy to be proactive.
- If possible, end-of-shift audits or concurrent chart checks to capture those opportunities when the nurses are still charting.
- Report the audit findings directly to the nurses to gain buy-in and involvement.
PC.01.03.01 EP 1 — Individualized Care Plans
(PC.11.03.01 EP 1; SPG Page 138)
Common Findings:
- Generic Care Plans: Plans were not always tailored to patient-specific needs, such as pain management, fall risk, diabetes, or post-surgical recovery. For example, if a patient is assessed as no risk of falling or is assessed that pain is not an issue with this admission, if surveyors see that falls or pain are listed on the care plan, they will likely want to understand why and see some type of documentation in the chart that triggered the need in the care plan.
- Failure to Update: Care plans weren’t always initiated or updated in response to patient reassessment, new diagnoses, or changes in condition. For example, in the behavioral health setting, when a patient experiences a restraint episode, the treatment plan or care plan is required to be updated to reflect the restraint. Additionally, updates from diagnostic tests, such as a CT scan that reveals evidence of a stroke, should be reflected in the care plan along with any corresponding interventions.
- Missing Consults: Required nutrition, dietary, or specialty consults were often not ordered or documented when indicated by assessments.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
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Failure to have an accurate and comprehensive care plan can be a factor contributing to a condition-level deficiency. For example, investigating a patient’s fall during a survey would involve several steps, including using the appropriate screening tools, adhering to policy, implementing fall risk strategies, and updating the care plan to reflect the patient's fall risk.
- Develop a care plan audit tool and audit the patient’s health record, preferably concurrently, as much as your time permits.
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Encourage the use of the care plan as a working document, as it should tell the patient’s story. The care plan document or screen should be able to describe priorities, timelines, and an evaluation (ongoing or progressing is not an evaluation) of how the patient is progressing toward the goal. Interventions to achieve the goal should be readily available, as they will need to be adjusted if the plan is not effective (i.e., the patient is not improving or meeting the goal within the documented timeframe).
PC.01.02.01 EP 1 — Patient Assessment and Reassessment
(PC.11.03.01 EP 1; SPG Page 138)
Common Findings:
- Incomplete Assessments: Required nursing, psychosocial, or vital sign assessments were sometimes missing or incomplete. For example, suppose a patient is having a procedure in an ambulatory surgery area, and the pre-op nursing assessment screen is blank except for vital signs. In that case, the surveyor will request a multitude of documents, including policies and procedures, competencies, and will require assistance in understanding why the standard of care for pre-op nursing documentation differs in the ASC when the pre-op policy mandates a head-to-toe assessment.
- Documentation Gaps: Blank or partial forms, especially for intake assessments or pain evaluations, were frequently found.
- Failure to Follow Orders or Protocols: Staff occasionally failed to follow physician orders or monitoring protocols, such as documenting RASS, CPOT, or CIWA scores after interventions. We find these issues in the intensive care units, emergency departments, or telemetry units, although these findings could be located anywhere a patient is under a CIWA protocol.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey: Observations in this standard could lead to a condition level deficiency requiring a revisit. I would highly recommend developing an audit tool for any medication order with a clinical endpoint. Citations in this standard, on occasion, can lead to additional chart reviews to “pull the thread” and identify a system issue.
Observations from an internal chart audit can be utilized as a valuable multidisciplinary performance improvement project, potentially leading to enhancements in how orders and policies are written.
MS.01.01.01 EP 5 — History & Physical (H&P) Documentation
(16.01.01 EP 1; SPG Page 14)
Common Findings:
- Missing H&P Elements: Key components such as review of systems, family history, or medication lists were often incomplete. Many surveyors use internal checklists in addition to the required elements from internal hospital policies.
- Timeliness Issues: H&Ps and discharge summaries were not always completed or signed within required timeframes (e.g., 24 hours or 30 days). For example, if a history and physical comes from an office practice outside the health system, that H&P may be outside the 30-day rule and will need to be addressed. Audit those H&Ps to ensure there are no issues with these documents when faxed to Pre-Op or pre-admission testing.
- Credentialing and Privileging Gaps: Some providers performed services outside approved privileges or lacked documentation from required committee approvals (this is a simple one and sometimes overlooked): Providers in the ED administering sedation without privileges. Sometimes these are temporary providers or from a contract service.
Leadership - Here’s what this means for hospitals preparing for the 2026 survey: Depending on the tracer activity, this finding could lead to or be a contributing factor to a condition-level deficiency.
- The medical staff office will require specific clinical content from all clinical areas to ensure that the necessary privileges are granted. Develop an audit checklist and periodically review files randomly to identify any skips or oversights. As a charge nurse or director of a specific unit, if you see a new provider, resident, etc., double-check to make sure they have the privileges needed to provide care on your unit.
PC.03.01.01 EP 1 — Pre-Anesthesia Assessment
(SPG Page 306)
Common Findings:
- Missing Pre-Sedation/Pre-Anesthesia Documentation: Airway assessments, ASA classifications, and other required exam details were often absent or completed after the procedure. Be prepared to review medical records with the surveyor. The anesthesia evaluation is typically reviewed, starting with the date and time of the evaluation, followed by its content. Add anesthesia evaluation to your surgical audit form!
- Policy Noncompliance: Some providers skipped essential assessment elements (e.g., airway, NPO status, Aldrete score) or had unauthorized personnel performing assessments. Blanks in the template are an issue. It is always helpful to have an anesthesia provider in attendance during this portion of the document review.
- Timing and Completeness: Assessments were sometimes backdated, lacked timestamps, or were incomplete—missing cardiovascular or pulmonary evaluations, for example. Sometimes I find too much “cutting and pasting” from other parts of the medical record, and either the content is not applicable to the patient or the time of the “pasting” is either completed too late (after surgery).
Leadership - Here’s what this means for hospitals preparing for the 2026 survey:
- Operative and invasive procedure charts are crucial, and I cannot stress enough the importance of proactive chart audits. Including the chief of the anesthesia department or the chief of surgery or both will help close gaps and deficits. It is highly likely that findings in this area will result in a follow-up survey.
Final Thoughts
As we move through the Top 15 standards, the findings underscore the critical importance of complete, timely, and individualized documentation for both patient safety and survey success. Consistent reassessment, accurate care planning, and adherence to policy not only supports compliance, these practices also directly enhance quality of care.
If you have any questions regarding the content of this article or how to address noncompliance proactively, please do not hesitate to contact me by email at gnash@nashhc.com or by phone at 915-241-7830. My colleagues and I are very happy to help.
Have a great week and see you next Sunday
Gayle Nash, MPH, RN
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