MDS Alert

Don't chance scrambling to get surveyors the information they need when you can have the resources needed to have it ready.

The new long-term care survey is intimidating and complex, but you can save yourself some stress by making sure you're prepared to meet surveyors at the door.

First, make sure you're very familiar with the new Entrance Conference Worksheet. You can find the link at the end of this article.

Your facility's administrator and director of nursing should meet surveyors at the door with documents in hand and a game plan in mind.

Make a binder or workbook with all of your survey-necessary documents, and make sure you update it before and during your survey window, says Maureen Kelly, senior consultant at LW Consulting Inc., in Harrisburg, Pennsylvania, during a webinar.

Right off the bat, be ready with:

• Your facility's census number;
• A completed matrix including residents who were admitted to your facility in the last 30 days and still reside there;
• An alphabetical list of all residents in your facility - including those who aren't physically in the facility at that moment, which you should note on the list; and a
• List of residents who smoke, and your facility's designated smoking times and locations.​

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But go ahead and beef up your binder now with other information surveyors are going to need, including your facility's policies and procedures for

• smoking,
• prohibition of abuse,
• outside food (like that which is brought in by visitors),
• anything related to dialysis care,
• and flu and pneumococcal vaccinations.

Top tip: Include your facility's Wi-Fi network access information, too, Kelly says.

Accessing information via EHR or hard copy records. Once surveyors schedule the entrance conference, you'll need to provide more documents and information, even though the entrance conference worksheet says verbal confirmation will suffice for some items. Help yourself by adding these to your binder:

• A copy of the entrance conference form;
• Information, including name, location, and phone number of the full-time director of nursing;
• Information about your facility's emergency water supply;
• Current facility floor plan (keep this updated, especially if your facility has undergone changes); and
• Name of resident council president.

The surveyors should provide someone on your staff with signs announcing that a survey is in progress, which need to be posted in high-visibility areas. The surveyors should also provide the facility with a copy of the CASPER 3.

Top tip: Most new admissions may not have completed MDS assessments or have the MDS transmitted to the state prior to survey, but it's critical to complete the survey matrix for all new admissions, Kelly says.

Logistics can get hairy when you're providing high-quality care to so many people; though you and staff may have working knowledge of protocols and daily routines, you'll need to have that information on paper to satisfy surveyors. Do yourself a favor now and cut down on stress by itemizing and compiling the day-to-day information surveyors now require.

Include a paper listing the current schedule for mealtimes, as well as the locations of dining rooms and room trays. Compile copies of all of the menus, including therapeutic menus, for meals served for the duration of the survey.

Go above and beyond: Include a page that outlines your facility's policies for food brought in by visitors, too, Kelly suggests.

Surveyors will require information on all of your facility's medication practices. This includes:

• the schedule for your medication administration;
• the number and location of your medication-storage rooms, as well as any medication carts; and
• the location of any medical device storage rooms.

Beware: Surveyors will be checking out the location and security of your medications and medication storage, including any refrigerators, Kelly says. Stay ahead of the curve by knowing what temperatures the fridges should maintain for medication storage, and have evidence ready. Pay special attention to your narcotics storage; if you use a box, make sure it's locked and secured.

Surveyors will also be looking much more closely at the competency and scheduling of your staff. Go ahead and get in the habit of keeping all the following information current, printed, and on hand in your survey binder.

Some of the staffing information surveyors will want immediately includes:

• the schedules for all licensed and registered nursing staff for the duration of the survey period;
• a list of key personnel in your facility, as well as their locations and phone numbers - you should make a note of which employees work on a contractual basis, such as those who provide rehabilitation services; and
• specific educational qualifications of paid feeding assistants (see item 17 on chart below), if your facility uses their services, and which residents are eligible for assistance.

The new survey process is so nuanced and complex that it warrants more than one article just to get through the first day in the process. Check back next month to find out what else you need to know.

In the meantime, find the entrance conference worksheet and provider matrix here: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Guidancefor­LawsAndRegulations/Downloads/LTC-Survey-Entrance-Conference-Provider-Matrix.zip.