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key component in a successful long-term care survey is the management of the survey process. Management of the process starts well before the surveyors enter the facility and does not end at the exit interview. This article will address ways to best prepare your facility for a successful clinical survey. Before we begin, there are many common myths about the long-term care survey process that need to be addressed and dismissed. These include:

1. “If we take good care of the residents, survey will work itself out.”
        This is simply not true. Although taking good care of the residents is an important step in providing a good quality of life, Centers for Medicare & Medicaid Services (CMS) regulations focus not only on quality of care but also on documentation, monitoring, and evaluation of that care. Lack of documentation of the care provided will leave a long-term care facility at risk for “immediate jeopardy” deficiencies and subsequent sanctions, an inability to admit, a loss of operating license, and poor staff morale.

2. “Surveyors need to be escorted to the nursing units and monitored at all times.”
       In the first hour of the surveyor’s arrival, a tour of the facility is conducted. The surveyors can find their way to and from the nursing units and often use this time to observe staff interactions with residents. Having the Director of Nursing (DON) and/or nursing managers consistently in their workspace can be distracting and tense. Although the surveyors need space to do their job, someone knowledgeable about clinical policy and procedures, medical record order, and resident care plans should be available to answer questions as they arise. These staff members should be in the sights of the surveyors.

3. “Facilities should stack their staff during survey so they’re putting their best foot forward.”
       If you need a certain number of staff to provide “survey” quality of care, then that is the number of staff members you should have on each day. Facilities have done this time and time again and have only had negative consequences. Surveyors can determine sufficient staffing in many different ways, one of the most frequent being resident complaints of unanswered call bells. If a survey team receives a number of resident complaints directing the team to insufficient staffing, the surveyors will request copies of past and future schedules. Additionally, this practice instills bitterness in your staff. Calling in extra staff during survey just reinforces the fact that you already know they work short-handed and allows the practice to continue at all times except for survey. If your staff members start to vent their frustrations of this to the surveyors, a deficiency becomes unavoidable.

Beginning Your Self-Survey

       A facility’s self-survey never ends. Along with assessing its ability to provide quality care, a quality of life, and financial stability, the facility should assess its survey readiness. The hallmark program for preparing for a successful survey is an effective quality assurance (QA) program. The QA program acts, in one of its capacities, as the final check to ensure compliance with regulations. The facility may develop an effective policy, but the QA is the safety net to ensure the policy is followed.
       An effective QA director tends to be task-driven and detail-oriented. A series of checklists can effectively ease the task of building the safety net. For example, Federal Tag 225 (Tag F225), Abuse and Neglect, requires a series of reporting requirements and interviews with staff and residents; there is almost always a need for action to be taken. Most facilities develop a file for each incident. At the front of that file can be a standardized checklist noting that all

Figure 1

requirements have been met. Not only does this close the investigation at completion, but it enforces to the surveyor that the facility uses the guidance in the regulations to conduct an abuse/neglect investigation (see Figure 1 for an example of a abuse/neglect checklist that can be torn out and used).
       An effective QA program can use these checklists to assist in compliance in numerous areas, including accidents, injuries of unknown origin, pressure ulcers, and medication errors. Once this system is set up and running efficiently, the facility has organized its files to deal with an impromptu survey. Any member of nursing management who has been involved in survey realizes the importance of having all of your information in one file. This allows you to concentrate on explaining the incident to the survey team, showing the excellent job you did on preventing a further incident—not running from department to department looking for different pieces of the abuse-file puzzle.

Preparation of Staff

       Preparing your staff for survey is an ongoing process. Giving your staff the tools needed to do well in survey promotes teamwork and instills self-confidence in the nursing staff. Consistent education and training for all staff on the survey process develops confidence in the staff that survey is a facility-wide process and not just for senior management-level nurses.
       It is wise to conduct ongoing mock surveys, which involve all levels of staff. During the mock survey, interview staff on the facility’s abuse and neglect policy and resident rights. Surveyors will frequently choose line staff, including licensed nursing assistants (LNAs), housekeepers, and maintenance staff, to interview on these processes.
       One of the most stressful survey tasks for line staff is the supervised medication pass. Educate your nurses on the regulations regarding timing, disposal, and refusal of medication. During scheduled or unscheduled mock surveys, perform supervised medication passes with your regular nurses. Use this as an educational, not disciplinary, tool.

Developing Expertise

       Developing expertise in clinical staff is essential to embracing the team approach. Although the DON should be knowledgeable about standards of practice, policy and procedures, and specific resident issues, team leaders should be appointed and developed to have a high level of clinical expertise in specific areas. For example, the wound care team leader should be a nurse with extensive continuing education in the treatment of decubitus ulcers or a registered nurse (RN) who is certified in wound care.
       Having different members of the nursing team with advanced clinical knowledge demonstrates to the survey team that the facility truly operates with a team approach. Similar requirements can be made for the team leaders for fall prevention, weight loss, and pain management.

Roles and Responsibilities

       There is nothing like the early-morning phone call to announce the beginning of survey to get your adrenaline pumping. Prior to the survey commencement tour, assigned staff should do a last run through of “environmental” rounds. Nurses can be assigned special roles and responsibilities for the first hour of survey. For example, one nurse is responsible for ensuring proper signage is posted where oxygen is in use, a second is responsible to ensure all the unit refrigerators have had a temperature recorded recently, and a third is responsible for just walking around and noticing anything unusual. Of course, all of these things should be monitored regularly. But they are often the areas that are overlooked, resulting in avoidable deficiencies.

Conclusion

       Managing your survey allows staff members to relax and put their best feet forward. Although survey is only one small part of the resident care picture, minimizing the stress during survey week will result in having happy staff members, which, in turn, results in better resident care. This is the outcome that we all strive to achieve.