Why Ongoing Audits Are Essential for Regulatory Compliance in Nursing Homes

Compliance isn’t just about passing inspections—it’s about protecting residents and building trust.
At Senior Care Solutions, we believe ongoing audits are the key to stronger compliance programs and better care.

In the ever-evolving landscape of senior care, regulatory compliance isn’t just a box to check—it’s a cornerstone of quality, safety, and trust. At Senior Care Solutions, we believe that ongoing audits are one of the most powerful tools nursing homes can use to stay ahead of regulatory requirements and deliver exceptional care.

Proactive Protection, Not Reactive Scrambling

Regulations from CMS, state health departments, and accrediting bodies are complex and frequently updated. Without a system of regular internal audits, facilities risk falling out of compliance—often without realizing it until a surveyor arrives. Ongoing audits allow teams to:

> Identify gaps before they become citations

> Stay aligned with the latest regulatory changes

> Build a culture of accountability and continuous improvement

Audits as a Lens for Quality Improvement

Audits aren’t just about compliance—they’re about care. When done thoughtfully, they reveal patterns that impact resident outcomes, staff performance, and operational efficiency. For example:

> Reviewing residents with wounds to ensure timely and thorough assessments are occurring,
use of proper treatment and assistive devices, and accurate care plan

> Auditing care plans can ensure they reflect current assessments and resident preferences

> Examining infection control practices such as proper use of Enhanced Barrier Precautions,
can highlight training needs or workflow breakdowns

Each audit becomes an opportunity to elevate care—not just meet minimum standards.

Data-Driven Decisions and Documentation

In today’s regulatory environment, if it’s not documented, it didn’t happen. Audits help ensure that documentation is:

> Timely

> Accurate

> Aligned with billing and reimbursement requirements

This is especially critical in areas like MDS coding, PDPM transitions, and Medicare compliance.
A strong audit trail supports defensible claims and reduces the risk of denials or penalties.

Empowering Staff Through Engagement

When audits are collaborative—not punitive—they empower staff. Involving frontline team members in the audit process:

> Builds ownership and understanding of compliance standards

> Creates space for feedback and innovation

> Reinforces that quality and compliance are shared responsibilities

At Senior Care Solutions, we encourage facilities to use audits as coaching tools, not just checklists. Circle back with staff to have a 1:1 education.

Building a Resilient Compliance Program

Ongoing audits are the backbone of a resilient compliance program. They help facilities:

> Prepare confidently for surveys and inspections- schedule audits on a calendar and have a process
for QAPI review for accountability.

> Perform the audits with front-line staff so they can better understand the “WHY” behind what they are
required to do.

> Trends are quickly identified when performing routine audits. Facilities can use to mitigate risk and
provide guidance for ongoing educational programs and competency needs.

> Demonstrate commitment to excellence to residents, families, and regulators.

In short, audits are not a burden—they’re a strategic advantage.

Final Thought

Compliance is not a one-time event—it’s a daily practice. By embedding ongoing audits into the rhythm of operations, nursing homes can safeguard their mission, protect their residents, and lead with integrity.

Michelle Stober, RN, BSN
CEO

For more information contact
consult@srcaresolutions.net

Read More:

MN Case Mix Transition Plan to Section GG: A Strategic Roadmap for Senior Care Providers

As the October 1st transition approaches, MN nursing facilities must pivot from Section G to Section GG within the Minimum Data Set (MDS). This change isn’t just regulatory—it’s an opportunity to elevate documentation practices, team collaboration, and resident-centered care.

Survey-Ready Nursing: Using Policies and Procedures to Lead with Confidence

As a Director of Nursing (DON) in a skilled nursing facility, survey readiness is always on your radar. But what if your policies and procedures could be your secret weapon—not just for compliance, but for confidence.

The Importance of Effective Medication Administration Delegation in Assisted Living

Medication administration is a vital care component in assisted living facilities. To ensure residents receive their medications safely and on time, many facilities delegate this responsibility to unlicensed personnel (ULP). When done properly, delegation supports care continuity, efficiency, and resident well-being. However, improper delegation can lead to errors, non-compliance, and potential harm.

Reduce Immediate Jeopardy Tags With Appropriate Sling Use

High staff turnover and COVID-19 focus on infection control have led to more regulatory scrutiny in nursing homes. Inappropriate sling use is a growing concern. Facilities should ensure proper sling size, documented plans, staff training, and regular audits to prevent resident injuries.

Soothing Solutions: Creative Approaches to Pain Management in Nursing Homes

It is often a struggle for nursing homes to develop comprehensive pain management strategies.

WHAT, WHEN and WHY of an Investigation

WHAT, WHEN and WHY of an Investigation: What Warrants an Investigation

Are Use of Electric Recliners Lifting You Toward a Deficiency?

A powered recliner may be considered a physical device which may be used by or for the care of a resident to promote, supplement or enhance resident’s function and/or safety. To ensure the residents’ safety, it is recommended to have this device included in your physical device assessment and ensure that it is appropriate for use and added to the plan of care.

Skilled Care Reimbursement: Recipe for Reimbursement

Blog Post by Michelle Stober RN, BSN, PHN, CEO Senior Care Solutions — The MDS assessment is your invoice for getting paid and unless you are occasionally checking the coding of your “invoices” you might be losing out on significant revenue.

The Benefits of Mock Surveys in Hospice

Mock surveys rehearse official inspections for hospices, pinpointing areas for improvement before real surveys. This helps staff prepare, identifies weaknesses, and boosts confidence.

Lores Consulting and Senior Care Solutions Proudly Announce their Strategic Partnership!

Senior Care Solutions (SCS) announces a partnership with Lores Consulting, expanding into Home Care and Hospice services. Lores Vlaminck, a retiring expert, joins forces with SCS's Michelle Stober. Both are passionate about quality care and aim to serve a wider client base. SCS is also affiliating with relevant industry groups in Minnesota.

Get Updated on the 2022 Legislative Changes to the Assisted Living License

This blog by Julie Dietz summarizes changes to Minnesota's assisted living laws. Key changes include updating resident rights regarding privacy and adding contact info for complaint reporting. The assisted living contract must now include termination grounds and the facility ID number.

Latest Updates on the MDH Assisted Living License Survey Trends

This blog post by Julie Dietz, a senior assisted living consultant, summarizes the most common deficiencies found in recent Minnesota assisted living facility inspections.

Is Your Coffee Too Hot?

This blog post warns about the burn risk from hot coffee in healthcare facilities. While coffee should ideally brew at 195°F, safe drinking temperature is much lower (155°F can burn in 1 second!). Lowering brewing temperature sacrifices flavor. The solution is to prevent spills with locked machines, air pots, travel mugs, etc. pen_spark

How Supplemental Nurses and Caregivers Can Help Your Assisted Living Staffing Plan

This blog post tackles healthcare staffing shortages. It highlights the use of supplemental staffing agencies and offers 3 key tips for facilities: 1) Verify agency accreditation, 2) Ensure staff meet facility requirements, and 3) Conduct thorough agency orientations. These steps help maintain quality care and compliance during staffing shortages.

Five Creative Ideas for Leaders to Help Keep Your Team Engaged

We offer tips for leaders to bring fun into the workplace. Ideas include holding meetings in new locations, having team lunches, taking walks, incorporating fun elements into stand-up meetings, and organizing monthly team-building activities. It emphasizes that having fun boosts morale and shows investment in employees.

Navigating the Holidays through Grief

The holidays can be tough for those grieving. This blog post offers tips for coping, like acknowledging your feelings, creating new traditions, and setting boundaries. It also suggests honoring your loved one and practicing self-care. Remember, grief is personal, so be kind to yourself.

The Heart of the Holidays: Meals in Assisted Living

Assisted living holiday meals are social events, but food safety is crucial. Staff should prioritize proper hygiene, temperature control, storage, and kitchen checks. Consider adaptations for resident needs while maintaining festive flavors. By following these tips, communities can celebrate safely and spread holiday cheer.

Nursing Home OSHA Ergonomics Program Law Effective 1/01/24

The 2023 Legislative Session passed a law effective January 1st , 2024 stating healthcare entities must have an ergonomics program (healthcare entity includes Nursing Homes).

Hospice Compliance and Oversight

A recent surge in concerns about hospice care quality led to stricter regulations. The Hospice Act of 2021 requires tighter oversight, improved quality metrics, and stronger patient protections.