Long-Term Care Survey Alert

When it comes to surveys, often the biggest thing your facility has to fear is fear itself.

"Anxiety interferes with staffs ability to handle the survey well," says Beth Klitch, principal of Survey Solutions Inc. in Columbus, OH, who has seen nursing assistants get so scared of doing or saying the wrong thing during the survey that they hide in stairwells or bathrooms or even become physically ill.

A monthly "survey drill" on all shifts can help alleviate this performance anxiety, according to Mary Knapp, senior director of ZA Consulting in Jenkintown, PA. The drill involves assigning selected CNAs to be "surveyors" so they can get used to viewing the process from a regulators perspective. The mock survey team then uses a checklist to observe how well the staff is prepared for the survey, especially in the care areas of resident activities, dining, and providing support for activities of daily living.

"The entire survey exercise should be couched as an effort to promote awareness of the survey process not as a fault-finding mission or performance review," Knapp emphasizes. "The more experience staff have looking at the survey as a performance improvement opportunity rather than as a punitive one- or two- day experience, the less fear they will have during the actual survey," she says. "They will feel more confident and less affected by the hustle and bustle and hype of the survey."

Claire Hoffman, principal of Hoffman Associates in Royersford, PA, agrees. She advises facilities to break down mock surveys by targeting different services or parts of the regulations on a monthly basis. "You do nursing services, or plant or infection control, or dietary, each month and by survey time, its like theres nothing different going on."

Hoffman also advises facilities to conduct ongoing resident and staff interviews as part of the survey drill. "By interviewing residents, you will find out things that you can address proactively before surveyors are on-site," she says. For example, a resident may say that the staff dont answer the call lights quickly, which is not something you want to hear a resident say on survey day.

"By doing resident interviews, you also help the residents feel more safe during the survey process, which can be intimidating to some residents," Hoffman adds.

Klitch recommends facility administrators repeatedly practice with CNAs answering the kinds of questions surveyors are likely to ask. "Its not like you are giving the CNAs a script, but you want them to get used to how to answer," Klitch says.

For example, if the surveyor says: "Tell me about Mrs. Joness problems," a nervous CNA might answer: "She is incontinent, demented, and falls a lot," providing a clear road map to further inquiries or even F tags for a variety of issues.

On the other hand, CNAs can create the "Wow!" factor with surveyors, Klitch says, if they are taught to answer by pairing up a solution to any resident problem that surveyors ask them about. "So in reviewing Mrs. Joness problems, the nursing assistant would say, She is incontinent, so we check and change her every one to two hours and we have her on a toileting plan where we prompt her to use the toilet every two hours. And she has some dementia so we put the call light where she can easily see it; and she has fallen in the past, usually trying to get to the toilet, so we make sure to toilet her before she tries to get up on her own."

Its also a good idea to get staff used to being observed doing procedures and interacting with residents as part of the survey drills. That way the "halo effect" can take over during surveys, where people who know they are being observed put their best foot forward rather than in their mouth. "Anyones hands are going to shake if the only time they are observed passing a medication or giving a bath is by a surveyor," Klitch notes.

Administrators have to demystify the survey experience for staff and for themselves. "If leadership is afraid of whats going to happen, they will impart that message to the staff," notes Klitch.

To inject a healthy sense of perspective, remind staff that surveyors arent "mind readers." They know which residents have triggered quality indicators or the facilitys previous survey history because they have done their off-site preparation.

Administrators should also avoid the trap of hoping things "magically" go well during the survey. "You have to prepare for the survey every day and keep CNAs informed about the residents condition, changes in regulations and expectations," says Marilyn Mines, a nursing consultant with FR&R Healthcare Consulting in Deerfield, IL. "If you try to do all of that only for the survey, your anxiety level will be very high and you are setting yourself up for failure."