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Previously I started sharing a bit of information with you about the nursing home survey and how a nursing home surveyor prepares to conduct a survey. I want to continue to give you a short overview of the preparation of the nursing home survey process.

The standard survey in a nursing facility is composed of Tasks, just like the Hospital Survey has tasks. The QIS Standard Survey has 9 Tasks and the Traditional Standard Survey has 7 Tasks. Both versions of the survey process are resident-centered, outcome-oriented inspections that rely on variety in the sample of residents in order to determine if the facility is in compliance with skilled nursing facility participation requirements. Outcomes include both actual and potential negative outcomes, as well as failure of a facility to help residents achieve their highest practicable level of well-being.

 

  • A standard survey determines a variety of things, including:
  • The nursing home’s compliance with residents’? rights and quality of life requirements;
  • The accuracy of residents’ comprehensive assessments and the adequacy of the care plans the nursing facility did;
  • The quality of care and services furnished by the nursing facility; and
  • The effectiveness of the nursing facility?s physical environment to empower residents to be as independent as possible, to accommodate resident needs, and to maintain resident safety.

 

If the nursing home surveyors determine that the facility is providing a substandard quality of care in any one or more specific categories, the survey can be extended. Those areas that can be determined to have substandard quality of care are:

  • Resident Behavior and Facility Practices (42 CFR 483.13);
  • Quality of Life (42 CFR 483.15); and/or
  • Quality of Care (42 CFR 483.25)

Extending the survey means the nursing home survey team will spend more time at the facility and expand the areas of focus and the number of residents they will look at.

There are some other survey types in addition to the Standard and the Extended survey. These types are: Abbreviated Standard Survey (which focuses on particular tasks and areas), Partial Extended Survey, (which is conducted if substandard quality of care is found during an abbreviated survey), and a Post-Survey Revisit or Follow-Up survey, which is conducted to see if the facility corrected the violations found on the previous survey.

As you can see, there is much to a nursing home survey process. In the next post, we will continue the discussion on the nursing home and hospital surveyors process during a survey.

Keep safe and informed!

JL

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As with hospitals, skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with their requirements, which are located at 42 CFR Part 483, Subpart B, in order to receive payment under the Medicare or Medicaid programs. Unlike hospitals, SNFs and NFs have two types of standard surveys. The traditional survey and the quality indicator survey (QIS) are the two types. The QIS survey is the “new kid” on the block and CMS developed it to try and improve the quality and consistency of nursing home surveys. Both types are currently accepted by CMS to evaluate compliance of nursing homes with their requirements.

Currently, most states are using the traditional survey. QIS training is intensive, long, and only CMS-approved training agencies and training materials may be used by the States to train their surveyors in the new process. It is also a much more expensive survey to conduct because of the cost of the training and the computers needed. This is one reason why it has not been pushed as extensively as CMS would like.

The QIS is intended to be implemented as a replacement for the current (Traditional) survey process. The QIS has two-stages and the process has a computer component to it. Stage 1 consists of computer analysis of offsite data as well as computer analysis of the data collected by surveyors from observations, interviews, and record reviews of large computer-selected resident samples. Stage 2 of the QIS consists of systematic surveyor investigations of specific issues and residents using the Guidance to Surveyors as well as a set of detailed investigative tools, called critical elements protocols. In addition to the two Stages there are also several facility-level tasks that are completed either on every survey or when the task is considered an area of concern.

The Stage 1 information is analyzed by the surveyors computer and a set of approximately 160 Quality of Care Indicators (QCIs) are the result of the analysis. These QCIs are used to compare the nursing facility being surveyed to national norms. Any QCIs that score beyond a particular statistical threshold are then computer-selected for a Stage 2 review. The computer also selects a sample of relevant residents.

As with Hospital surveys, the nursing home surveyor and the team will arrive at the facility unannounced. As with the Hospital surveys, the nursing facility surveys may be conducted at any time including weekends, 24 hours a day.

We will continue this in the next post.

Be Safe! Be Knowledgable!

JL

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In the previous posts we started discussing the various tasks in a hospital survey. We are now at Task 4 of the tasks that a nursing home and hospital surveyor must do during a hospital survey.

In Task 4 the hospital survey team takes all their findings and integrates them. They review and analyze all the information collected from observations, interviews, and record reviews, and they determine whether or not the hospital meets the Conditions of Participation This initial decision-making and analysis of the findings assist the hospital surveyor team in preparing an exit conference report. The hospital surveyors share their findings, evaluate the evidence, and make decisions as a team regarding the hospitals compliance with each requirement. If the hospital survey team determines it needs additional information in order to determine if the hospital is in compliance with the regulations, the team coordinator decides the best way to conduct the additional review.

Task 5, the Exit Conference, is to inform the facility staff of the team’s preliminary findings. Most times these are friendly, non confrontational conferences, while other times there can be an air of hostility. It is CMS’s general policy to conduct an exit conference at the conclusion of each survey. However, there are some situations that justify refusal to continue or to conduct an exit conference. For example: the nursing home and hospital surveyors may refuse to conduct the conference if a facility lawyer tries to turn it into an evidentiary hearing. Also, if the facility creates an environment that is hostile, intimidating, or inconsistent with the informal and preliminary nature of an exit conference, the nursing home and hospital surveyors may refuse to conduct or continue the conference. If the facility wishes to audio tape the conference, it must provide two tapes and tape recorders, recording the meeting simultaneously. The surveyors then take one of the tapes at the conclusion of the conference. Video taping is also permitted, at the sole discretion of the nursing home and hospital surveyor(s) and if it is not disruptive to the conference, and a copy is provided at the conclusion of the conference. After the exit conference, all of the team members will leave the facility together immediately.

Task 6 covers the preparation of the Statement of deficiencies, receipt of the hospital’s plan of correction, and the timeline for any other type of action taken, such as decertification. This is something we can discuss much further in future posts.

Be informed and be safe!

JL

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In the previous posts we started talking about how a nursing home and hospital surveyor conducts a hospital survey and the various steps, or tasks, involved. We are up to task 3.

Task 3, the Information Gathering and Investigation phase, focuses on actual and potential patient outcomes, as well as the processes the hospital is required to have in place. It is during this time that the Hospital Survey team assesses the care and services provided to the patients. The Hospital Surveyor will visit all the patient care settings, including inpatient units, outpatient clinics, anesthetizing locations, emergency departments, imaging, rehabilitation, remote locations, satellite locations, etc. The members of the team will observe the actual provision of care and services to patients in every area of the hospital and the effects of that care. The team constantly communicates with each other in order to determine if they have any critical issues. The survey team members can also decide to have a hospital staff member accompany them or to go about the facility without an escort. Personally, I usually find it prudent to have staff come with me for several reasons. They can answer my questions or find someone quickly who can, they can get me from one unit or area to another without me needing a map, and they are witnesses to issues I find as I go about the hospital. If I want to privately interview a staff, patient, or visitor, I ask the accompanying staff to leave.

As an aside right here, I find it quite annoying when there are 6 or 8 staff following my every move. Several questions come to my mind in those instances:

  1. Who is caring for the patients if there are 6 or 8 people following every surveyor
  2. What are they afraid I will find that they want 6 or 8 people following me around? One staff accompanying me is enough, and sometimes two is OK as one can go find an answer to a question while the other continues to go around with me.

I will say, it is interesting (and funny) to see staff  “scurry” when a hospital surveyor approaches. I remember on one survey how I was going around with 1 staff member and there was another who kept disappearing around the corner every time I turned around. I wonder if she thought I didn’t notice her disappearing every time I turned around.

The hospital staff often have many questions and will ask a hospital surveyor for his or her guidance on how to correct a problem. Because the team is a representative of a regulatory agency, it is not in the role of a team member to provide consultation. Some states, though, do allow some limited consultation with the facility. The problem is that the hospital or facility then says, “But the state said……”

The hospital surveyor will also do a comprehensive review of care and services received by each patient in the sample. A comprehensive review includes observations of care/services provided to the patient, patient and/or family interview(s), staff interview(s), and medical record review. Observations provide first-hand knowledge of hospital practice and provides valuable information about how the care delivery system works and how the hospital’s departments work together to provide care. Interviews provide a method to collect information, and to verify and validate information obtained through observations. Document review focuses on a facility’s compliance with the Conditions of Participation. Documents reviewed may be both written and electronic and include but are not limited to patient?s clinical records, personnel files, credential files, maintenance records, staffing documents, policy and procedure manuals, committee meeting minutes & records, and contracts.

In the next post we will continue with our discussion of the steps and processes that a nursing home and hospital surveyor follows when conducting a hospital survey.

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