A patient in a North Carolina nursing home was allowed to fall by a nurse aide. The aide and her friends/coworkers covered it up and for two weeks the patient was untreated for a hip fracture. She was eventually taken to a hospital and there it was found she had a broken hip. Shocked by the news, the family eventually was able to find out what happened. The resident’s family learned what happened only by reviewing follow-up reports from state inspectors.

As we know, rules and regulations get through “channels” and many times they do so without anyone noticing. That has happened again. A recent change in federal rules on nursing home inspections makes it nearly impossible for families to get the information they need to protect their loved ones.

According to the associated press, the changes were put into effect in October 2008 with little notice and without a public comment period. The change is getting sharp criticism for closing off critically important information. Under the new rules, the state inspector follow-up reports can’t be released without specific approval from the chief of CMS.

“It’s an extremely troubling development – it puts a lot of information related to nursing-home inspections off-limits,” said Eric Carlson, director of the Long-Term Care Project of the National Senior Citizens Law Center, a California-based nonprofit group funded in part by the federal Administration on Aging. “I think it’s certainly bad for consumers and the folks who represent them.”

The change bars nursing home surveyors from releasing privileged information to the public without approval from the Director of the Centers for Medicare and Medicaid Services. State employees (the nursing home and hospital surveyors) who perform inspections for the federal government have been reclassified as federal employees as part of the revision. This reclassification is only for this purpose, and not for wages/benefits or other purposes. The surveyors are still state employees. They contract to the Federal government to perform the surey and certification work and as such are required to follow federal standards and procedures, and in this case, are required to follow the federal procedures for the release or non-release of privileged resident/patient information.

Officials at the Department of Health and Human Services said employees have been too burdened by requests for information. Under the rule change, state employees who inspect nursing homes for the federal government are reclassified as federal employees who aren’t allowed to provide “privileged” information or documents to the public without approval from the head of the Centers for Medicare and Medicaid Services.

Requests were diverting employees from certification responsibilities, Michael Leavitt, secretary of the Department of Health and Human Services, said in announcing the change.

Lawyers are now finding out that the new rule has already slowed efforts to represent their clients. It is slowing down the process to get the information they need.

How does this affect you, the consumer? – You can see, it is putting a wall in your path to ensuring your loved ones are getting safe care.

What about those of you who are administrators and staff of nursing homes – now is it affecting you? You might think at first, that it is a good thing, but really, getting information out to the public about both GOOD and BAD state inspections is beneficial to the facility and to those who are wanting to look at where to place their loved ones.  I would think even those who administer nursing homes find the change in rules, without a public comment period, to be a poor decision.

Then look at who has to give the permission – the head of CMS – the head of a federal agency is going to review and provide permission for the hundreds of requests in every state? That sounds like an impossible task, the permission is either going to be given or withheld willy-nilly. What determines who gets permission to see the documents and who doesn’t? Will there be criteria? Who is developing that criteria? What patient rights are being stepped on here?



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After the nursing home survey team has finished with the survey, the members will then write the issues they found. This writing is done on the “Statement of Deficiencies”, commonly referred to as the “2567”. The number “2567” refers to the number CMS has assigned to the statement of deficiencies form.
The statement of deficiencies is written in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met. This is when the team will also make a final determination of the level of Severity and Scope. You can refer to my previous post on “The A to L of Nursing Homes” to understand a little more about how surveyors grade a nursing home.
So that is just a little bit about how a nursing home surveyor prepares to conduct a nursing home survey and the tasks they must perform during the course of the survey.
Now you must remember that because of the process of sample selection, the nursing home survey team does not look at every resident or patient in a nursing home or hospital. Because of this, there are many times that problems within a nursing home or hospital are not found. This is where it becomes so important for you, the public healthcare consumer, report the problems you find to the local licensing & certification agency who conducts these surveys. You are, in essence, a second set of eyes to help the survey agency know where to look and who to ask. Even then, though, it can become quite difficult to “prove” anything. It is becoming frequently more common for nursing homes and hospitals to challenge the findings from a survey. If the nursing home team does not have all the information to show the failure to follow the regulation the deficiency can be “thrown out”. So when you do report your complaints to a survey agency, give them as much information you can, including names, dates, specific times, actions, etc. The more you can tell them the better the nursing home surveyors chances are in substantiating your complaint.

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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!


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I am in the midst of explaining some concepts to you about how a nursing home surveyor prepares to conduct a nursing home survey. This is Part 3. I talked a little about the two forms of Survey, the QIS survey and the Standard survey. I want to explain, now, the Tasks for the QIS nursing home survey that the nursing home surveyors must do.

The QIS Tasks are:

  • Task 1: Offsite Survey Preparation. This includes an initial resident sample selection. During this task the nursing home surveyors also review files, previous complaints and surveys, and other information in order to be familiar with the issues the nursing home survey team might encounter while at the nursing home.
  • Task 2: Onsite Preparatory Activities and Entrance Conference. This is where the nursing home survey team lets the facility know what to expect during the survey. The team gathers additional paperwork and nursing facility information and continues to develop the plan for the survey.
  • Task 3: The Initial Tour. Upon entering a nursing facility the nursing home surveyors do a tour of the facility prior to commencing with the investigative portion of the survey. This is different than a Hospital survey in that hospital surveys do not have an initial tour.
  • Task 4: Stage I Survey Tasks. These include finalizing the sample selection, conducting nursing home survey team meetings, gathering information, reviewing records, and interviewing staff, residents, and families.
  • Task 5: Non-Staged Survey Tasks. This includes more interviews, reviews of policies and procedures, Abuse Prohibition review, Quality Assessment and Assurance review, observation of the food services, and reviews of billing.
  • Task 6: Transition From Stage I to Stage II. During this stage of the QIS process the nursing home survey team updates the resident sample, reviews what was found in Stage I, puts data into the laptop and reviews the analysis of the findings (the QCI’s mentioned previously)
  • Task 7: Stage II Survey Tasks. This is again composed of more sampled resident reviews, team meetings, more investigation, observation of the Medication administration, Environmental observations, reviews of resident funds, reviews of admission, transfer and discharge issues, and facility staffing.
  • Task 8: Analysis and Decision-Making. This is where all the information is integrated and analyzed in order to determine what areas are non compliant.
  • Task 9: Exit Conference. This is where the nursing home surveyor and the team provide information about their preliminary findings to the nursing home.

In the next post we will continue with the process a Nursing Home and Hospital Surveyor follows when conducting a nursing home survey.

Keep informed and keep safe!


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