Long-Term Care Survey Alert

Starve - don't feed - the F tags by eliminating these common survey ills.

If your facility can't shake a case of F-tagitis or appears to be coming down with one, perhaps your survey management systems need a care plan.

Use this checklist to see if your facility suffers from any of the common problems known to cause a major survey headache - and, if so, implement the prescription for a cure long before your next inspection.

1. Super DON Syndrome. Consultant Beth Klitch has heard surveyors mutter this epithet under their breath as they watch the DON fly around answering call lights, fighting crises and taking over the duties that CNAs normally perform. "The DON may feel like she's doing the right thing, but she's actually creating chaos and conveying to the surveyors that she, in effect, doesn't trust the staff," says Klitch, president of Survey Solutions Inc. in Columbus, OH. 

"The irony is that the DON may not know the residents as well as the CNAs or may not even be doing the care right, because he or she doesn't usually do those nursing procedures," Klitch offers.

The cure: Work with staff to let them know they are the experts about the residents and the ones providing their care. Also make clear that you expect staff to portray that image to surveyors, advises Pam Barbour, RN, COO, with Waterman Village in Mt. Dora, FL.

2. Surveyor Avoidance Syndrome. This problem occurs when staff suddenly find things to do everywhere but within sight of the surveyors, says Klitch. Then the surveyors look down the empty hall and start wondering about staffing shortfalls. "And that can take the survey in the wrong direction," Klitch cautions.

The cure: Implement strategies to to shore up staff's self-confidence during surveys. For example, conducting mock surveys and regularly observe nurses performing med pass and treatments, advises Klitch. 

3. 'You Are Your Weakest Link' Syndrome. This phenomenon occurs in facilities that, for whatever reason, never identify or bring a poor performing caregiver up to speed, says Joseph Bianculli, an attorney in Arlington, VA. "A capable nurse or caregiver who makes a mistake can fix it or defend her clinical rationale to surveyors," he notes. "But surveyors will seek out and go for that weakest link in the nursing staff," Bianculli warns. "And that's the staff person who is going to do the facility in at survey time each and every time."

The cure: Develop systems to evaluate staff competencies on a regular basis. Retrain and/or counsel caregivers who don't meet the facility's standards. Rethink the wisdom of keeping bad apples under the rationale that "beggars can't be choosers" in a nursing shortage. (For tips on creating an environment that attracts staff, see Case Study: Are Staffing Shortfalls Landing Your Facility With A Long CMS 2567?)

4. Survey Sabotage Syndrome. Staff may not have much incentive not to vent to surveyors about the care or staffing ratios in poorly managed facilities. "They may perceive that if the facility gets cited, the care or their staffing load may improve," warns Klitch. And you can bet surveyors will buddy up to that disgruntled-looking CNA in an effort to get the inside scoop on the facility.

The cure: Solicit and address staff complaints and suggestions on a regular basis. For example, "the quality assurance committee can form a subcommittee to interview a diagonal slice of the facility's staff - a couple of CNAs, LPNs and department heads" - and find out what they'd like to see change, Klitch suggests. Then address their concerns within the limits of the facility's reimbursement and practical realities, she advises.

"Also, if your facility has a good QA process, it should be getting concerns with the quality of care to bubble up to the surface on a regular basis," Klitch adds. "The same is true for mock surveys." (For the inside secrets to making mock surveys really work for your facility, see the next issue of Long-Term Care Survey Alert.)

And don't stop with staff. Interview residents and family members to identify and address their concerns before they unload them on surveyors' sympathetic shoulders.

Cut to the chase: To tap into residents' concerns, read the last three sets of resident council meeting minutes and look for repeating themes, Klitch suggests. "Is the food  still cold after three months' worth of meetings airing residents' complaints about the issue? If the facility's quality indicators show residents have an unintended weight loss problem, the surveyors are going to put two and two together," she says.

5. Asleep During the Survey Syndrome. Don't end up like one administrator who walked into work on a Monday morning to find out a survey team had been in the facility all weekend - and the report wasn't good.

The cure: "Facilities need a protocol for how staff should handle an unscheduled survey or one that starts during the evening or weekends," advises Reta Underwood, a survey consultant in Louisville, KY. "Frontline staff should always greet strangers, as surveyors are required to identify themselves" if asked, she adds. The staff should then follow a clear policy and procedure spelling out whom to contact immediately (the administrator, DON, etc.) and how to manage the survey process in the interim, Underwood suggests.

6. Roll Over and Take the Deficiency Syndrome. Some facilities don't realize there's room for negotiation with the surveyors before they write up the CMS 2567 (statement of deficiencies). For example, Barbour headed off a fairly serious survey citation recently by standing up to a surveyor - literally.

During the exit conference, the surveyor said she was going to write up the facility and Barbour stood up and said: "No you're not!" relays Waterman Village's executive director Dale Lind. Barbour then asked the surveyors to get the regional office supervisor on the phone. The upshot of the situation: The facility didn't get written up.

As Barbour explains, "The surveyors were confusing their terminology with our terminology in claiming we weren't doing something for a resident, and it just wasn't true."

Some facilities don't understand how to use the exit conference to convince surveyors they're off the mark with their concerns, she adds. "And once a deficiency ends up on your 2567, it's much harder to get it removed than if you have the dialogue with surveyors beforehand," Barbour notes. "Once it's on the statement of deficiencies, the facility is looking at legal fees usually" to challenge it.

The cure: Understand how the survey process works before, during and after the survey. "Know the procedures the surveyor uses, including the MDS-generated quality indicator reports, resident sampling and the survey protocols spelled out by the State Operations Manual," advises Bianculli. "Use the process to your advantage as an advocate for your facility and residents," he adds. 

7. The Survey Window Frenzy Syndrome. This problem occurs when the facility sprints into a mad dash to "catch up" on its survey preparation in the three-month window before the annual survey. Ironically, the resulting disruption to normal operations can create chaos and anxiety to the point that residents suffer negative outcomes during that time period, cautions Lind.

The cure: Develop real-time quality assurance and contemporaneous documentation processes. "If you are identifying and meeting residents' needs on a daily basis ... your survey will fall into place," advises Kathy Hurst, JD, RN. Hurst heads up human resources and operations for Anaheim, CA-based TSW Management, which manages several nursing facilities in California.