Long-Term Care Survey Alert

Published on Wed Apr 27, 2005 PDF

Recent surveyor training provides roadmap out of F tags.

When in a survey, do as the surveyors do ... determine whether your facility really deserves a deficiency.

The Centers for Medicare & Medicaid Services is now suggesting surveyors use an analytical framework to make that determination, according to March 18 surveyor training, "Making Sense of Data." The training Webcast focuses on how surveyors should use information collected during the survey to determine compliance with requirements of participation.

View the Webcast at www.cms.internetstreaming.com.

CMS recommends surveyors use five modes of "differential thinking" during the survey, culminating in a judgment as to whether the facility is in compliance. Knowing these steps can give your facility an edge in heading off F tags.

1. Fact gathering and reporting. Using this mode of thinking, surveyors have to know what the regulations actually state, emphasized Webcast presenter Vittorio Santoro, PhD, a consultant to CMS on survey issues. For example, surveyors should know that 483.10(g) (F167 and F168) says residents have the right to examine survey results, said Santoro.

Be proactive: "The more familiar the facility staff becomes with regulatory requirements, the more prepared they will be to validate the survey process during the survey," says Gene Larrabee, a consultant in St. Augustine, FL.

2. Decisions based on rules. Surveyors must comprehend the meaning of the requirements and interpret them consistently.

3. Analytical observation. This mode requires the surveyor to apply or use a concept in a new situation.

Example: The nursing home has a locked wing to protect residents with Alzheimer's or other forms of dementia. Using this form of thinking, surveyors should ask themselves: How does 483.10(g) apply in that circumstance (that is, if the resident can't access or understand the survey results)?

The regulation doesn't say that only mentally competent residents have the right to examine survey results, Santoro noted.

4. Synthesis. This type of thinking requires the surveyor to integrate different pieces of information to create a whole picture.

Example: A resident has the right to a surrogate if adjudged incompetent by judicial or administrative proceedings, said Santoro. "That surrogate then makes decisions for that resident," he added. Thus, in assessing the facility's compliance with 483.10(g), surveyors would look to see if a resident with dementia has a surrogate decision-maker - and, if so, whether the facility makes survey results available to that person, said Santoro.

5. Making a judgment. The survey team decides whether the data meet the threshold to determine a facility is in compliance with requirements of participation. The surveyor makes that decision within the regulatory framework, including the statutory requirements, and with the assistance of the interpretive guidelines and survey procedures.

Thus, in determining compliance with 438.10(g) (the resident has the
right to review the results of the most recent survey), the surveyors note that the facility displays the survey results in the activities director's room which is open only from 9 a.m. to 5 p.m. Monday through Friday. Therefore,  the survey results aren't available to residents or their surrogates, said Santoro in the Webcast presentation.

In this case, the State Operations Manual Appendix PP backs up that conclusion. The manual says survey results and the approved plan of correction, if applicable, should be "available in a readable form, such as a binder, large print, or are provided with a magnifying glass ... and are available to residents without having to ask a staff person."