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s nursing home requirements continue to evolve and statistics and information become more accessible to the Centers for Medicare & Medicaid Services (CMS) and the public, the survey process becomes more complex. This significantly affects the assignment of nursing home managers to maintain continuous compliance with federal regulations. The good news is that nursing home managers, including nurse assessment coordinators (NACs), can utilize this same information to identify potential trends, implement effective strategies, promote positive outcomes, and increase the likelihood of continuous compliance and successful surveys.
       Today, the campaign to assure quality care in nursing homes is driven not only by CMS and consumers but by nurse executives who effectively take on the task of assuring that individual resident needs are responded to, regulations met, and services provided to achieve better outcomes—resulting in enhanced quality of life.
       As a result of the Institute of Medicine (IOM) study to improve the quality of care in nursing homes, facilities are now required to be in compliance with 42 CFR Part 483, Subpart B of the Federal Standards for Nursing Home Care in order to obtain certification and receive payment for Medicare and Medicaid programs. Compliance is determined by a standard survey process that takes place at least annually and complaint investigation surveys that occur at any time. Having a clear understanding of the regulations, how regulations benefit each resident, and the components state surveyors use to measure compliance during a survey is an important first step in promoting successful surveys. CMS’s State Operations Manual (SOM) provides survey protocols and instructions regarding the survey and certification process and describes Omnibus Budget Reconciliation Act (OBRA) regulations governing long-term care facilities, including each regulation, its intent, and related interpretive guidelines.
       In order to be survey-ready every day, nurse managers and nurse assessment coordinators should remember the four Ds: Define, Develop, Deliver, and Document.
       1. Define policies and procedures and ensure that they are realistic and up to date with current standards of practice and reflect the intent of the regulation. Nurse assessment coordinators must be sure that policies and procedures accurately define Resident Assessment Instrument (RAI) processes and care plans reflect resident-directed best practices.
       2. Develop systems for how programs will be carried out based on policies and procedures. Communicate information about systems to all staff members who will be involved with carrying them out. Nurse assessment coordinators must ensure that accountability systems are adequately developed to manage and carry out the RAI process.
       3. Deliver the care in the manner that is consistent with policies and procedures. Does the actual facility practice reflect the policy and procedure? The NAC must organize the RAI so that the process is timely, resident-directed, and correctly completed by the appropriate interdisciplinary team members. The only way to make sure that the facility is delivering high-quality care is to do every day what state surveyors do when they arrive at the facility:
• Observe staff in action
• Listen to staff members’ inter actions with residents
• Review documentation and the medical record
• Interview staff members and residents.
       4. Document the inconsistencies or trends and report them to the director of nursing (DON), and have the NAC review the documentation. Take credit for all the facility’s hard work. Make sure the facility’s documentation system is concise, efficient, and consistent. Avoid redundant charting.

Everyday Activities for Survey Readiness

       Some facilities seem to wait until the survey window opens to begin talking about survey preparation; however, this approach often communicates a “hurry up and clean up our act” mentality. Staff members will see through the efforts to beef up staffing right before an expected survey. Setting a goal to be survey-ready every day will send a strong message to residents, staff, and the community that the facility is committed to high quality care.
       Use Minimum Data Set (MDS) data in the same way surveyors will. Most software applications have report functions so that the facility can query data to extract key information that will assist the facility with daily quality assurance (QA) activities. To ensure accuracy, look for residents who are considered high-risk, and systematically review the records and care plans. Then go observe residents and staff members to ensure that the care is carried out in a manner consistent with the plan of care.

Table 1

       Incorporate review of facility reports into daily routines, and include all management staff in the process. Follow up on each issue to ensure that potential problems are addressed promptly. Some nurse managers insist that at least four hours per day be spent in monitoring activities. (Table 1 includes reports that the facility should already be preparing and can be easily integrated into daily rounds.)
       Being survey-ready every day is all about taking a proactive approach to leadership and management. It is about making a commitment to prepare every day and do the right thing all the time—not just when someone is watching. The four Ds of survey readiness provides a simple way to structure daily management activities by asking these questions:
• How is it defined?
• Has it been developed?
• Was it appropriately delivered?
• Has it been well-documented?