Long-Term Care Survey Alert

Here's what they need to know to win the day.

Surveys can be traumatic for CNAs ... but if these frontline workers really know the OBRA ropes, they can protect your facility from F tags - and even have fun in the process.
 
"With the right preparation, CNAs can make the survey a 'game' where they compete with themselves to keep their patients off the CMS 2567 (statement of deficiencies)," says Richard Butler, principal of Survey Management Services in Indianapolis.  By "game," Butler means a healthy competitive spirit where CNAs go into the survey with an attitude of "No one is going to write an F tag involving my patients because I know the regs and I'm following them."
 
But to create that kind of scenario, facilities must provide CNAs with the ongoing training to help them really understand what the survey process is all about, and what the regulations realistically require them to do, Butler emphasizes.    

Empowered with that knowledge, CNAs can identify and correct their errors during the survey, which can potentially head off a deficiency, or at least mitigate it. "When nursing assistants do something that's not quite right when the surveyor is watching, they should know to merely correct themselves and move forward," Butler says.
 
The regs don't say CNAs have to be perfect, Butler adds. "Thus, isolated human error should not be viewed as regulatory noncompliance, as long as it's not a pattern and hasn't harmed a resident," he emphasizes.
 

Say the CNA forgets to change gloves in between residents and even touches the resident on his arm while the surveyor is watching. In such an instance, the CNA can simply say to the surveyor: "I'm sorry, I am nervous and made a mistake. I know I should have changed gloves," and then follow the correct procedure by removing the gloves, washing her hands and cleansing the patient's arm where she touched, Butler advises. (If the CNA touched a wound instead of intact skin, she should get the DON or nursing supervisor involved in deciding what to do.)
 
CNAs should also know to immediately report to their supervisors that they made a mistake, how they corrected it - and the surveyors' response to the incident.
 
Of course, to know when you've broken a rule, you have to know what the rule requires, and any exceptions to it. For example, sometimes you'll see CNAs running around the halls wearing gloves, "but the CNA who really understands the regs knows she doesn't have to wear gloves all the time," Butler observes. "And the Centers for Disease Control & Prevention doesn't say caregivers have to wear gloves every time they touch a patient. So if the CNAs know and follow the simple principles to prevent transmission of infection, they will feel confident that they are not breaking the rules.

Document the Incident
 
If CNAs fess up to and correct a minor mistake during a surveyor's observation, the surveyor will often let it go, relates Gene Larrabee, principal of Primus Care Inc. in Valparaiso, IN. Former Ohio survey chief Kurt Haas agrees. "For CNAs to immediately correct a problem ... speaks volumes about their priorities and values and can give surveyors the justification they need to exercise professional judgment about issuing a citation or not," says Haas, a consultant in Lithopolis, OH.
 
Even so, Larrabee advises the facility to document the fact that the CNA corrected the misstep. Then keep the information in an administrative file in case you need to rebut surveyors' concerns during the exit conference or during IDR or on appeal. "You're probably going to know if you need the documentation when you talk to surveyors at the end of the day at the mini-exit," Larrabee says.
 
What if the CNA makes a mistake during the survey that causes the patient harm? "You can't retrieve harm," Butler says, "so you just have to deal with it and take steps to prevent it from happening again." But even if the CNA dropped a patient, it might have been an unavoidable accident - for example, the patient could have suffered an unexpected seizure or the caregiver may have sneezed violently, he says. Therefore, don't assume it was the caregiver's fault without first checking into what happened.
 
Documentation Tip: In cases where a surveyor observes a situation where a caregiver's action caused potential or actual harm to a resident, Larrabee suggests the facility consult with its legal counsel about how to document the incident. "You don't want to hide anything under the rug," he says. But you also want to protect the best interests of the facility so that you don't falsely assume responsibility for something in writing before you've investigated it thoroughly.

Target QA Concerns
 
CNAs should also know the facility's quality assurance problems and issues cold to ensure they follow the regulation and any best practices used by the facility (see related story, "Use CPGs to Improve Care And Survey-Proof Your Facility"). "Everyone on staff, including CNAs, should be extra careful in handling those issues at all times and especially during the survey," Butler suggests.
 
Let's say a facility isn't happy with its system for preventing unplanned weight loss, and its QA team is doing a root-cause analysis of the problem. "During the survey, nutrition and hydration must be upper- most in the CNAs' minds," Butler says. For example, make sure CNAs can calculate meal percentages or dietary intake accurately using the facility's protocol. "And the CNAs must be careful in the dining room in assisting residents to eat and make supplements and snacks a major focus for the facility," Butler suggests.
 
Butler also advises giving CNAs a "heads up" a few days before the survey explaining that the residents whom they care for regularly will probably be in the resident sample. "You can say, 'It's likely Mrs. Smith or Mr. Jones will be in the sample. Maybe not, but let's just plan on it,'" he advises. That way, the CNA has time to get used to the idea and can review with the nursing supervisor or DON what she will be doing for the resident during the survey.
 
Tip: Want to inoculate staff against survey performance anxiety? Regularly evaluate the CNAs and even LPNs perform nursing and other care procedures. "And ask someone the caregivers don't know to do the observation, which puts the pressure on so they get used to it," Larrabee suggests. "For example, you might ask a retired RN to come in and do the job and participate on the QA committee."
  
Editor's Note: The information provided by Richard Butler in the above story is part of a presentation he will give at the Illinois Health Care Association's annual convention in October 2003.