Long-Term Care Survey Alert

The inside secrets to a perfect survey record may be simpler than you think.

Getting through even one survey without an F tag on your slate can seem like a real feat these days - but it's one that Hillhaven Assisted Living Nursing and Rehabilitation Center in Adelphia, MD has pulled off for eight years in a row.

But the family-owned and operated nursing center never considers this record an excuse to rest on its laurels. "We try to be survey ready every day with our documentation, care processes and a quality assurance system that deals with issues in real time," says DON Kimberly Malin, RN.

Secret to success: "During the survey, we do what we do well to meet residents' needs every day of the year," says Malin.

The administrators and DON also have all of the paperwork required for the surveyors ready to go when the survey begins, which starts the survey off on the right foot.

Then the administrative staff stands by to provide additional information and documentation - a survey management strategy that has been known to head off an F tag in the making. In one situation, for example, a surveyor questioned the facility's nutritional care plan for a resident with end-stage disease who was losing weight due to her condition. And the interdisciplinary team's answer - and trail of documentation - convinced the surveyor not to write up the facility. "The surveyor felt we weren't giving the resident enough variety in supplements, as these included only puddings and ice-cream," says the DON.

So the staff chronicled for the surveyor how the resident's care plan had evolved over time and included input from the resident's family.

"The medical record and care plan showed that the staff had tried various dietary interventions and different supplements and feedings methods - for example, the rehab therapists had worked with the resident on feeding skills," says Malin. "And we felt that the puddings and ice-cream were the best intervention for that resident" at the time, she adds.

Lesson learned: Documentation can save the day, but the caregivers have to know the resident well enough to be aware of her care plan history. "If you have high staff turnover, the staff won't be familiar with the residents and know what the team has attempted to do to address a problem over time," cautions Joyce Malin, RN, NHA, the facility's administrator. "The care plan is always a work in progress."

Develop the Ties That Bind

What impact, if any, does keeping the facility "all in the family" have on its survey record? Hillhaven can count the ways - and they are all lessons that any facility could apply.

For one, as owners and managers, the Malins are in the facility on a daily basis and are known for paying attention to details so things don't slip through the cracks. The facility has strong community connections, serving as a clinical site for several area nursing assistant and nursing schools, as well as secondary education programs and activities.

The facility also has very low staff turnover, which the Malins say they accomplish by welcoming staff to the family and providing them the tools to care for residents well. For example, as part of orientation, Hillhaven teaches the staff about the survey process, the regulations and the requirements to meet them - and the facility's own policies and procedures.

In fact, one of the biggest survey mistakes Joyce Malin believes facilities make is having staff who don't know and follow the facility's own policies and procedures when providing nursing and other care. (The other biggest mistake: "Having a hostile environment toward surveyors.")

Another secret to keeping staff over the long haul can be summed up in two words: positive feedback. "The  response CNAs get from residents and families - in addition to ours - helps them feel valued for their important work," says Joyce Malin.

Stay on Top of Pressure Points

Hillhaven has also developed QA processes to stay on top of central survey issues, such as pain management and the quality indicators (QIs). A drug-regimen review committee, which includes charge nurses, looks at residents' pain management and the overall use of pain medications in the facility.

"The facility's clinicians manage residents' chronic serious pain with long-acting pain medications and PRN pain medications for breakthrough pain," reports DON Malin.

The QA team also tracks the facility's pain quality measures. "As the result of our proactive pain management, we have less use of behavioral medications because we rule out pain as being a cause of behavioral symptoms," Kimberly Malin explains. The staff assesses residents with dementia carefully for underlying painful conditions and does a thorough behavioral assessment. "Then we look at the impact of the pain medication regimen on the resident's behaviors."

The facility addresses its QIs in real time. While the QA committee reviews QIs monthly, the team "anticipates what's coming on the report because they know when a resident triggers on a QI," reports Kimberly Malin. "We  implement care plan interventions as they are needed," she says.