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I discussed with you a bit about the Tasks one expects to see a nursing home surveyor conduct during a “QIS” nursing home survey. Those tasks are different than those conducted in a traditional nursing home survey. A nursing home surveyor will have 7 tasks in a traditional survey.

Task 1: Offsite Survey Preparation. This is where the nursing home survey team identifies issues that might be seen based on their review of documents that include the previous survey, the facility’s history of survey compliance and a review of the facility’s complaint history. During this time the team will also gather information from a database to compare the facility to others in the state and the nation. Concerns of the ombudsman are also reviewed. There may also be issues the team is aware of such a news reports, lawsuits and such. This information is also reviewed prior to the survey to help identify issues that need reviewed during the survey. During this time the team may decide they need specialty surveyors to attend the survey.

Task 2: Entrance Conference/Onsite Preparatory Activities. During this time the team coordinator informs the facility’s administrator about the survey and introduces team members. The rest of the team then begins Task 3 (The initial tour) while the team coordinator talks with the Administrator and gathers additional information. The SOM requires the team coordinator get specific information during the time of this entrance conference.

Task 3: The Initial Tour. During this time the nursing home surveyor gathers information about concerns which have been pre-selected; new concerns discovered onsite; and whether residents pre-selected for the Phase 1 sample offsite are still present in the facility. The surveyors will attempt to meet and talk with as many residents as possible. The nursing home surveyors can do the tour by themselves or accompanied by facility staff.

Task 4: Sample Selection. During this task, which occurs after the initial tour, the nursing home survey team will finalize the issues and the sample of residents that they will concentrate on during the first phase (Phase I) of the nursing home survey. Most of the time the team will continue to use the set of residents they selected during the off-site preparation, but there are times when they will substitute other residents. The SOM gives the survey team specific instructions on how and why to do this.

The Phase 2 sample is selected after the team has completed most of the Phase 1 investigations and reviews. At this point the nursing home survey team has collected enough information to determine what areas they need to focus on during the rest of the survey.

Task 5: Information Gathering. This is often considered the “meat” of the survey. The instructions given to the nursing home surveyors on conducting information gathering provides an organized, systematic, and consistent method of gathering information necessary to make decisions concerning whether the facility has met their requirements. Task 5 is divided up into 7 “subtasks”. These subtasks are:

  • 5A General Observations of the Facility
  • 5B Kitchen/Food Service Observations
  • 5C Resident Review: An overall assessment of the sampled residents
  • 5D Quality of Life Assessment: Assessment of the residents’ quality of life
  • 5E Medication Pass and Pharmacy Services: An assessment of the pharmaceutical services provided in the facility
  • 5F Quality Assessment and Assurance Review: An assessment of the facility’s Quality Assessment and Assurance program
  • 5G Abuse Prohibition Review: A review of the facility’s policies and procedures related to protecting residents from abuse, neglect, involuntary seclusion, and misappropriation of their property.

Task 6: Information Analysis for Deficiency Determination. This is the step in which the nursing home surveyors gather all the information they have obtained and they then meet together and review their findings. The nursing home survey team determines if the nursing facility has met or has not met all the regulatory requirements

Task 7 – Exit Conference. This tsk is to inform the facility of the survey team’s observations and preliminary findings.

Just becasue these tasks are  numbered doesn’t mean they all ocurr in an order. The ones at the beginning and end do, but the ones in the middle are all conducted pretty much simultaneously and continuously during the survey.

We will continue this in the next post.

Keep safe and informed!

JL

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3 Responses to “How a Nursing Home Surveyor Conducts The Nursing Home Survey – Part 4”

  1. Chicago Nursing Home Lawyer Blog Says:

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  3. admin Says:

    Thanks, Diablo. I do try to take the time to remove some of the spammy comments from people who aren’t even reading the site. I haven’t gotten to all of them though.

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