Survey 2012

My facility completed our state survey in November. This was 15 months since our previous survey. As I have discussed previously, these surveys are completed anywhere from 9 to 15 months apart. I would like to share some of what happens during a survey. This year we had 7 surveyors. Remember we have a 50 bed facility with 40 beds filled at the time. The process started around 9AM on a Monday and was completed on Thursday at 4PM. The new process is being used which is computer driven. What that means is that questions are answered on the computer that trigger more or less investigation depending on the answer. There are a lot of interviewes during the process of residents, staff and family members.The main problem for our facility was trying to keep up with 7 surveyors with a small staff. One of the most annoying parts of the survey was that 5 of the surveyors had to ask me (the director of nursing/administrator) the same questions. The following are some recommendations: 1. Make sure your residents know your policies and practices and that they report issues to you 2. Make sure staff understand all aspects of their job, this year they looked at restorative programs including documentation, staff and resident interviews 3. Make sure that if surveyors ask questions and or to watch procedures or to do meal temps that they report this to you immediately 1 resident reported that food temps were not always hot enough, the surveyor then asked for a test tray, the kitchen did not tell anyone this and during tray pass they did not tell the surveyor until after they fed the last resident instead of after the last tray was passed 4. A staff member stated that she did not do oral care ( without thinking ) and went back a few minutes later and said she did (too late) make sure they think about what they say 5. Make sure your family members know to report problems to you, a family member reported that sometimes their loved ones breath was bad (this is why they asked the NA about oral care) If I can recommend anything it is communication. Ask and answer questions to your staff, residents and family members.