Long-Term Care Survey Alert

If you think you're stuck with fiscal constraints, check out this key advice.

You don't want to spin your wheels focusing on an unfixable risk. But facilities can address the following areas to improve their outcomes and rein in liability insurance rates, according to a presentation by Nancy Augustine, RN, MSN, at the November 2009 American Association of Homes & Services for the Aging annual meeting.

1. Staffing levels that don't match changes in acuity levels. Staffing levels are "generally driven by census and budget," said Augustine, "and less likely to be driven by acuity" because long-term care doesn't have any great acuity models. But if you are taking a different type of clientele or resident that drives up your acuity level -- "you may have to address staffing."

2. Poor management and supervision. If you have bad management and supervision and higher turnover in key positions, you're probably going to have some riskier areas to deal with, said Augustine.

Put another way: "High turnover among nursing home management is like the canary in the coal mine," says consultant Barbara Frank in Warren, R.I. "It's an indication of very high stress levels in the building," she says. And continuing management turnover further fuels that stress, she warns. Staff have to get used to the new administrator or director of nursing and their new ways of working. "When this happens frequently, staff tune out new leaders, and wait for them to leave, rather than trusting in their leadership and make a new set of changes. It takes a long time for frontline staff to give the new leaders a chance."

Solutions: "Typically," says Frank, "many corporations have the morning phone call to go over the budget and census. The successful corporations have the phone calls that support leaders in good management practices and give leaders some leeway to work with their budgets to stabilize staffing. Stable staffing allows stable care, which increases census, and revenue."

For example, "a lot of corporations require staffing to census and don't listen to administrators who know the terrible impact of sending someone home who has come ready to work," Frank observes. In such scenarios, staff members may decide not to show up when they think they may be sent home. Then the nursing home may find itself working short and giving caregivers bonuses to pick up a last-minute shift, Frank warns.

3. Lack of access to financial resources and supplies. Constrained financial resources can affect whether the facility has low beds, pressure-relieving mattresses on all the beds -- "those kinds of things that have to be done to control high risk areas," Augustine pointed out.

"Lack of working equipment and resources can cause stress," says nursing home administrator David Farrell, with California-based SNF Management, noting he's had two CNAs get in a physical fight in the hallway over a mechanical lift. "Lack of everything is a stressor and causes arguments, and it's due to mismanagement."

Remedy: Facilities and organizations strapped for cash might take a hard look at whether they can do a better job of improving their bottom line. Attorney Chris Lucas often finds vast differences between facilities in the same geographical location in terms of how they achieve optimal revenues. He thus advises facilities to assess the revenue side of the equation by looking at their "marketing, payer mix, any special certification by third party payers for a subacute unit, as one example, and their reimbursement knowledge." Also look at how the facility works with referring hospitals, he adds -- for example, do you have someone in the hospital doing preadmission rehab evals?

4. Policies and procedures that set you up for failure. Augustine noted that she's read some policies and procedures for pressure ulcer risk management and treatment that are very thick. And those can be very difficult to follow.

Policies and procedures should also be realistic and not what attorney Paula Sanders calls "wish fulfillment." She notes that "surveyors have cited facilities that don't follow their own policies and procedures, even though the policies and procedures exceed the regulatory requirements." Thus, she advises facilities to make sure their policies and procedures meet the minimum regulatory requirements. "The facility can train staff at a level above that policy," adds Sanders, in private practice in Harrisburg, Pa.

"But if your policy is more stringent,surveyors may hold you to those standards," Sanders adds.

These may include "promises made that aren't always fulfilled," cautioned Augustine. Examples include language such as our facility "provides the best care in the area" or "unparalleled nursing and medical care." In fact, when Augustine worked for the Joint Commission, they'd pick up the phone book to see how a facility advertised itself before a survey visit. "Then we'd talk to them about that," she said.