Linda Elizaitis, President of CMS Compliance Group, discussed “Managing the Survey Process” for a LeadingAge New York audio conference for nursing home administrators, directors of nursing and other department heads. A review of 2012’s top survey issues in New York was provided, along with a discussion on the importance of systems in these areas. We’ve pulled together a few tips from Linda on how your nursing home can better manage its survey process, from preparation through the survey team’s exit.
- Be ready all the time – This seems simple enough, but in reality, many facilities are in the mode of prepping for survey only when they are approaching or are in their survey window. A pre-survey assessment, whether completed in house or by a nursing home consulting team, can evaluate your overall readiness. However, a few months before your survey date is not the time to try to update all your systems and expect your staff to implement and remember all the changes.
- Keep Care Plans up to date – Make sure that the staff responsible for updating the care plan make any changes in a timely fashion, implement the changes, and along with this ensure that the staff members responsible for providing care are all on the same page. An all too common situation is that changes to the care plan are made, but the CNA is not notified, nor are care cards updated to reflect changes.
- Develop measurable goals and appropriate interventions – Each resident’s situation is unique, which means their care plan should be as well. Goals for comprehensive care plans should be measurable, the CCP Team needs to take into account that vague terms such as “goal ongoing” do not provide sufficient information on where a resident is in relationship to the established goal and if revisions are needed. Appropriate resident-specific interventions should be documented and implemented.
Trying to get your team into the mindset that they should be prepared for a survey at all times will help ensure that systems are reviewed and updated on an ongoing basis to help ensure that your nursing home is avoiding potential “gotcha” deficiencies. Remember, it is as easy for a surveyor to observe, for example, medication administration or the pot washer mixing the sanitizer solution and identify compliance issues that you should have identified it first. The only way to prevent any deficiency from occurring is to take a look at your systems and policies regularly, making updates where required.