Skilled nursing centers should be survey ready everyday, but what does that really mean? We are humans taking care of humans, so it is important to have processes and systems in place to assist the team in consistency. Training is an important part of good survey management as well as good record-keeping. Utilizing tools to do self-audits will help the facility identify weaknesses and develop systems to repair the weaknesses. Know the regulations or where to locate them when needed. When the facility has systems and processes in place, the team does not fear survey, they manage it with confidence!
Create a Survey Book
The first step to survey readiness is a survey book with tabs. This book will send the message to the survey team that this facility is on top of everything. The book will need to be reviewed and updated on a regular basis. Prepare a procedure where the team members responsible for the tab in the book brings the required document as often as it needs updated. For instance, the CMS 802 needs to be updated daily, so the team member responsible can print and bring a new copy to the morning meeting.
The survey book should be brought to the morning meeting every day. Other tabs for the survey book should be: facility assessment, census, facility layout, list of key personnel with phone numbers, EMR sign-on and user tips, activity calendars for the last three months, menus, list of med-pass times, list of dining times and the location of each dining area, list of residents on hospice and hospice contract, list of residents on dialysis and contract, smoking policy, approved smoking locations and list of residents that smoke, name of resident council president, nurse staffing waivers if applicable and description of any experimental research occurring in the facility. In addition to these items, the facility may want to include the policies that will be requested, which are: Infection Prevention and Control Program Standards, Policies and Procedures, and Antibiotic Stewardship Program, Influenza/Pneumococcal Immunization Policy and Procedures, QAPI Plan and Abuse Prohibition Policy and Procedures.
The facility leadership should complete a facility system review utilizing the care pathways, survey questions and any other organizational tools for identifying weaknesses. Every weakness identified that needs improvement should have a QAPI/PIP plan in place that is approved by the QA committee and demonstrates thorough education of indicated staff with on-going monitoring. During the QA review of the survey process, this will demonstrate the facility has identified a concern, audited the system, provided necessary education and on-going monitoring.
Review your QMs to identify residents who may be the focus of the surveyors. Look at the residents who are flagging for areas such as catheters, wounds, falls (especially with injury), psychotropic meds, dialysis, decline in ADLs, tracheostomies and feeding tubes.
Educate employees on how to properly speak to surveyors. Use sample employee questions to prepare your team members for the survey. They should understand that anything said can and probably will become public record included in the 2567. It is important that staff know they can say, “let me get back with you” when uncertain of a response. Conduct resident interviews. Knowing what residents are going to say and acting on any concerns is crucial prior to the survey. Utilize the CMS survey interview forms to ask the same questions the surveyors will be asking.
Knowledge is key to confidence
It is important that your leadership team fully understands the intent of the survey. The survey should be a separate set of eyes doing an audit to ensure the facility is not missing anything. Review the CMS PowerPoint about the survey process and feel comfortable about what is happening. Every member of the leadership team should know how to get to Appendix PP and the federal and state regulations quickly. Review the CMS FAQs about the survey with your leadership team, as these are real-life scenarios with the answers. It will help to see that other providers have some of the same questions but will also help the leadership team acquire more knowledge about the survey. Print and laminate the list of F-tags so the facility leadership team will be familiar with the tags. Review the surveyor procedure guide with the leadership team so they will know what is happening each step of the survey process.
Preparation is key and working together with your team will ensure survey success and a good outcome. Don’t fear the survey, know your regulations and don’t be afraid to question surveyors on their interpretation of the regulation. Remember, they are humans too. If you need additional support, contact Deborah Franklin at [email protected] or 813-679-7533.