Editor’s note: The following post is an excerpt taken from HCPro’s new title, Survey Success for Long-Term Care: Reducing Citation Risk, by Diane Hislop, RN, a resource including practical, efficient ways to train and educate staff, perform internal audits and monitoring checks, and stay on top of the survey process.
Survey readiness is a 24-hour/365-days-a-year task. As part of this focus, facilities need to know their annual survey window cycle. After the cycle is determined, the facility should plan on some focused preparatory work items at the nine-month mark (nine months after the last survey). If the facility has had numerous complaints or is a Special Focused Facility, the window for work to begin is much shorter.
Below are four survey readiness activities, including:
- Resident council/resident interviews. This is a focal area for all survey processes/types today. Facilities should have methodology in place to conduct resident satisfaction surveys, focus groups, individual interviews, and Resident Council review. Any issues should be brought to the QA/QAPI meeting for follow-up and, as warranted, a plan of correction. I recommend that facilities utilize social work and activity staff to monitor Resident Council meetings/issues and to conduct follow-up interviews as warranted.
- Staff interviews. In the same vein as resident interviews, staff interviews are focal survey tasks. I recommend conducting mock staff interviews using a mix of personnel that are not direct reports or peers to conduct simple interview tasks around questions pertaining to issues such as grievances, staffing numbers, care plans, infection control, resident abuse, etc.
- Training huddles. These are quick meetings with line staff designed as a fun activity with quizzes or simple demonstrations around survey hot topics. I recommend five question quiz formats on key issues around care plans, transfers, resident rights, dignity, preferences, etc., that include some reward/opportunity for a reward based on correct answers.
- Mock surveys. This is a very key, important task for facilities that desire to develop best practice survey readiness skills and compliance processes. This process cannot be conducted by in-house staff, as it is impossible to achieve the critical analysis and insight required. In other words, a facility cannot audit itself. A consultant is recommended. The mock survey should encompass a full, traditional survey, even in a QIS state. This is the most encompassing review of compliance. All tags are relevant and must be reviewed.