Monthly Survey Spot Light January 2017

Over the next 12 months I am going to start a monthly survey spotlight. I will be discussing survey issues from experience, observation and current trends. I would love for people to share in these and make them a discussion on how to improve our survey outcomes across Ohio. I am tired of all of the negative press regarding nursing homes. I am seeing a huge jump in jeopardy level deficiencies and feel that this is one way to combat this. Please make comments and share your ideas and experiences.

Employee Records

The first area I am going to address is one that I have been seeing cited repeatedly in facilities and is very easy to correct. Inaccurate documentation in this are can be spread across several deficiencies including F225 and F226 abuse, F441 infection control and F497 employee records. It seems like we can all recite what is required but for some reason it just does not happen because of:

1.What I am seeing as the greatest cause of in accurate employee records is related to manager turnover and division of duties.

2. Employee records not maintained in the same area for example maintained in specific departments, managers files maintained in another location, contract employee files not maintained with other employee files.

3. Lack of training in preparing and maintaining employee files.

4. Access to paper work required for files.

Here is a short list of what the state focuses on during a survey in employee records

1. For new hires they focus on BCI log, references, proof of licensure/certification, orientation, Hepatitis B vaccine acceptance or refusal and TB

2. For State Tested Nurse Aides that have been employed over 1 year they look at all of the above and in addition to that they look at 90 days and annual evaluation, 12 hours of in-servicing for each, annual STNA specific competencies and annual TB

3. Nurses include an annual license verification and specific nurse competencies

Here are some suggestions for maintaining control of this area

1. Choose the gate keeper carefully. They must be trustworthy and very organized. Facilities come in all sizes and most do not have a human resources person so some other examples of appropriate positions are: receptionist, staff developer, scheduler or central supply person.

2. Once this person is chosen they will need education including what is required in an employee file, how it is organized, the rules governing employee records.

3. A safe secure locked cabinet for employee records.

4. A good copy of all forms

5. Allowed the time to maintain the records.

6. A list of all requirements for the file to be signed off on during processing to ensure that all the components are there.

7. Each department should sign off on the employee before the file is filed away.

8. I also recommend that the administrator also sign off on the record as well.

9. Complete audits of employee files monthly.

Leadership Definition Quote

I borrowed this quote but feel like it matches my own personal philosophy in regards to what leadership is truly about.

Leardership Quotations by Harry Selfridge

Over the last 2 years I have enjoyed watching the PBS series "Selfridges". I watched how the series showed him as a kind motivational leader. Even though he had a lot of vices he was loved by his staff. I found the following quotes that are attributed to him. I feel that these are still very modern ideas about being a manager that we can all use as we manager our facilities and staff.

"The boss drives his men; the leader coaches them."

"The boss depends upon authority, the leader on goodwill."

"The boss inspires fear; the leader inspires enthusiasm."

"The boss says 'I'; the leader, 'we'."

"The boss fixes the blame for the breakdown; the leader fixes the breakdown."

"The boss knows how it is done; the leader shows how."

"The boss says 'Go'; the leader says 'Let's go!'"

"The customer is always right."

Traveling

I know many of you will be able to understand that these type of problems are funny. Because if we didn't laugh we would cry. Well here are a few of my escapades. I have been working over 100 miles from home for a few months so there have been a couple.

I got a new travel bag and was very excited about it. I guess my life is pretty boring when I get excited over a travel bag. Well I had packed most of my stuff the night before and put some in my car. The next morning I got up and finished packing and put my bags in the car and headed to work. After I got off I went to the hotel and got my bags out of the car. I started looking for my new bag I loved so much and even rechecked the back seat and trunk. My car is a little Toyota so it was obviously not there. I had forgot my lovely new bag with all of my toiletries, underwear and shoes. At least I had cloths because they were on hangers. Thank goodness for Walmart.

I have sleep apnea and my husband gets mad at me because I won't use my CPAP machine. This is not a plea for sympathy I just think it's funny. Well after giving me a lecture he talked me into using it. I packed it the first week and he called me each night to make sure I was using it. The next week after I got to work I received a call from him and another lecture for forgetting the CPAP machine. Guess who drove it up to me that evening. I also got another lecture.

I had been staying in the same hotel for almost the entire time while working in a particular area. I usually asked my corporate contact to reserve my room for me but I forgot to do it 1 week. On Monday I called the hotel to make sure they had a room for the week and guess what? They did not have a room for the week. I contacted my corporate contact and told them they did not have a room for the week. I then received an email that I had a room in Columbus. I called another hotel which was about 25 minutes away but no traffic to deal with. They had a room. I emailed the office and asked them to change my reservation. They told me it had a 24 hour cancellation policy and could not be cancelled ( even though it had only been 15-20 minutes since the reservation was made). I bit the bullet and headed out with my GPS. The hotel was in the far north side of Columbus in Delaware right smack dab in the middle of a giant road construction site on the highway. I go in to check in and the receptionist tells me that the card the office used failed. I give him my card to use and then ask if I could cancel if I got a room somewhere else and he told me sure. I call the hotel I wanted to go to in the first place and make a reservation and after a total of 60 miles travel I reach my hotel.

National Nursing Home Week 2016

5 fun filled days to dress up and enjoy good food and games. Nursing Home Week is always special for the residents and the staff. Our staff have 5 fun days planned with:

Monday miss match

Tuesday support your favorite team

Wild West Wednesday

Tropical Thursday

Fancy Friday

National Nurses Week 2016

I put these pictures up to share how nursing has grown over the years. I included my own picture to see if any of my staff would recognize it.

Best Practices

I want to share the top 10 best practices that I feel make a successful facility. I do not take credit for these and have learned many of them through working in many settings. I feel that if you implement these into your daily practices you will be successful and have good survey results.
1. walking team rounds
      a. include nursing manager, MDS, social services, activities and dietary
      b. review nurses notes, telephone orders, 24 hour report, check MAR's/TAR's for holes errors medication availability, labs, x rays, ADL documentation
2. guardian angel program with daily rounds
3. morning meeting with all department managers
4. all hands dining
5. weekend manager program
6. monthly open door meetings
7. routine mock survey utilizing specialty service such as ABAQIS
8. stop and watch program with all staff involved to identify resident condition changes early
9. quick responses to all concerns including resident, responsible party and staff
10. an effective ongoing staff education program
   

Pinterest Ideas For Long Term Care

        Follow Mary's board Nursing Home Ideas on Pinterest.   

Being Fired

I have to admit I was not sure if I would share these stories but I feel as a leader we are always faced with the possibility that our performance does not meet or match what a company may expect from us. First I want to share my encounters with being fired. Yes I am admitting it and hope that I learned and have grown from them. I was actually terminated twice in my 40 year career. They were about 20 years apart.

The first time that I was fired I was a director of nursing in a small nursing home. I had worked there for 3 years. The company I worked for had 5 facilities. During that time I had developed a good team and had good results for surveys. This was just as OBRA was coming into play. During this time I worked for 3 different administrators. I had  what I thought was a good relationship with the owners. I was actually sent to some of their other facilities. In 1 capacity I did the CPR training for our other facilities and I also covered as  the director of nursing. Shortly after the third administrator started he came to me and said something like I have evaluated your services and we are going to let you go. He asked if he could pull my car up and got me a box for my things. Being a small facility I had to go by everyone and told one of my nurses I was leaving and wouldn't be back. She looked at me and said stop pulling my leg. I told her I wasn't and then broke down and cried. I left quickly and quietly and never looked back. I never was quite sure what happened but after a bit of searching I found work as a part time supervisor in a larger facility with a larger company. I was always honest about what had happened.

The second time I was terminated was less than 2 years ago. I had been doing independent contract work for over 1 year and loved it. Unfortunately my husband developed colon cancer and I had to find work that offered insurance. I became the administrator in a larger facility with a large corporate organization. During my time there I had a complaint survey almost monthly related to a disgruntled resident. I had 4 different regional directors. Was sent to help with yet another problem facility to help with their follow up survey. My building was census challenged therefore financially challenged. The last regional I had brought on a great regional nurse as well. I really felt like we were going to finally start seeing improvement. I had to fire several nurses for poor performance during this time but felt we had finally started to turn the corner. During the last few weeks I was employed I worked 10-12 hours per day 5-7 days per week and was starting to feel beat down a bit.

I remember the night before I was fired I felt like I got a second wind and had written up a plan and assignments to go over with my team. When I arrived that morning I asked the corporate nurse if she minded if I met with my team alone and she told me no. I guess I should have figured something was up. I then did my morning meeting and talked about goals and assignments. Again I should have figured something was up they were too quiet. I don't think they all knew but obviously some did. After the meeting I had someone to see me. The regional said they needed to talk to me and I asked if it could wait till I met with the people waiting on me and they said yes.

I met with my guests and then invited the regionals into my office. The regional vice presidents gave me a piece of paper to read. This paper said that I had basically caused the facility to loose money and  failed to improve census and clear survey issues. I was told I could sign the paper or write up my resignation. They told me if I did that they would pay me my earned vacation days. Of course I wrote a resignation.

My parting was a little bit funny to me. They asked someone to get me a box for my stuff and they brought a giant box. I had driven my little car so loading it I knew was going to be a challenge. I stuffed everything in the box. The regional said he would carry it and did. I know it was super heavy and my car was so small. He managed to get it in the car after a little bit of a struggle.
Well that is how I ended up doing what I am now as a floating administrator and director of nursing for problem buildings.

Here is the irony for those 2 situations. The first building I was fired from became one of my facilities as a regional vice president and regional nurse. The second building I was fired from was where I was working when at that time a different company sent me to school to get my administrators license and paid 100% of my tuition. If I learned anything from this it was to never burn a bridge. I never did or will speak badly of either of those facilities. Every thing happens for a reason.

Hiring Pains

I have been working in health care for 40 years with 30 of it in long term care. Yes, I know I'm too young to have worked that long, but I have. Well hiring has always been a difficult process but over the last few years it has gotten even more difficult. First of all the competition between healthcare settings is ruthless. With the reduction in our reimbursement, increase in expenses being creative and innovative in our hiring practices has become difficult.

I was recently working at a staffing challenged facility and trying to come up with ways to attract staff and get shifts covered. Well we offered a pick up a shift bonus to begin with. Next we increased it on the weekends. Then we started a referral bonus and then a sign on bonus. Before long we had STNA's making manager wages. We finally got a few STNA's hired on and about $25000.00 per pay more due to the incentives we were still running over 8% OT.

Our next attempt at improving staffing was to offer to send people to the nurse aide classes and pay their tuition. We had a lot of people interested and paid for 4 to go and at the end of the program only managed to maintain 1 at a cost of over $2000.00.

As soon as we started to feel a little better our competitor offered increased wages and a sign on bonus. Our current staff that were tired of working extra shifts were talking about jumping ship for what they felt was a better offer.

This problem is not only limited to line staff I have seen changes in how professionals and licensed staff approach the work force. I recently was looking for a DON in a facility and received 5 resumes on an online advertising program. I narrowed them down to 3 candidates. I made calls to all 3 and had to leave messages. I  received a call from 1 and set up an interview. The other 2 did not call back and the 1 I set up an interview with did not show up or call. Another position I was filling the person had accepted the job and gave notice to their company and assured me they would not stay no matter what they offered. Less than a week before they were to start they called and said their old company gave them an offer they could not refuse. I have seen DON's walk off the job which was unheard of 10 years ago.

I would like to challenge people to tell me their opinion or ideas on getting and keeping staff.

Pre School Programs and Nursing Homes

I saw a wonderful video today about a nursing home that had a pre school program in the facility. The video showed the interaction between the children and the residents. One of the scenes involved a resident and child that was trying to put on her coat to go home.They were both having trouble and the resident told the child "I can't even do it". They touched, held hands and helped each other. It was absolutely heart warming. This is something I think all nursing homes should look into. Intergenerational programs are so wonderful. When my children were growing up they spent a lot of time in nursing homes. They did their trick or treating in nursing homes as well as Easter and Christmas programs. So many children do not get to have grandparents in their lives and the residents miss their children and grand children. Providing this type of program could only be a win win situation.

Responsivness

I am writing this post to honor some amazing people I have had the honor to work with. In any service field including health care, the key to success is being responsive. The following are a few incidents that exhibit what being responsive means:

A confused resident comes to the front lobby frequently in their wheelchair. The resident is always asking the same thing (I want to go home and see my mother). Usually the staff get the resident a cup of coffee and take them back to their room. One day I heard the residents familiar voice asking the question of the day (I want to go home to see my mother). I heard an employee say can you hold the door and I will take her for a wheelchair ride outside. This employee did not have to do that. They could have done the usual thing coffee and return them to the unit.

My facility had been going through the process of changing our facility focus which resulted in a sudden drastic reduction in residents. I was faced with the challenge of reducing staff. An employee came to me and told me the they would reduce their hours so their co-worker did not have to. The employee said that their co-worker did not have any other financial support and they did.

My last responsive story is about a maintenance man that is the best one I have ever known. He covers all maintenance duties for a large  building that is 35 years old. One day I made rounds and discovered some potential infection control issues. I gave him a list that included replacing a sink and toilet, adding a sink to a utility room, a wall mounted cabinet to a utility room and putting new paper towel holders up in another utility room. I didn't give him the list till lunch time and he got all of it done in a couple of hours. This included going to the store to purchase sinks and cabinets. He also put all new mulch out and planted flowers in the courtyard without being asked.

I have seen many more incidents but these 3 really stood out for me.

Running An Effective Meeting

Overall effective meeting management can be accomplished when the project manager understands and is capable of effectively executing the following steps:

1. Properly Prepare for the Meeting
2. Select an Appropriate Location
3. Provide Food and Drink
4. Provide Necessary Materials
5. Establish Working Knowledge of Meeting Topic, Objectives, and Content
6. Keep the Meeting Less than an Hour
7. Ensure Everyone Gets and Completes Any Pre-Meeting Task
8. Help the Group Establish Ground Rules
9. Conduct Individual Introductions at Start of Meeting
10. Generate and Disseminate an Agenda Prior to the Meeting
11. Guide the Discussion without Forcing the Direction
12. Close the Meeting with a call for any Remaining Topics that need to be Addressed
13. Follow-Up the Meeting with Meeting Minutes that Include Action Items with Agreed Upon Deadlines

Borrowed From Effective Meeting Management by Mr. Stacey King MBA

Surprise

I went to the Activity Directors office to talk to her one afternoon. Her office is in the activity room and is an opened space. I sat with my back to the room talking to her. She got up and walked out and I picked up an Avon book to look at. Out of the corner of my eye I saw a man come up and get something out of the coat on the back of my chair. I thought it was my maintenance man who I have known for a long time and like to tease. I said "are you trying to touch me" and when he said "no" I knew I was busted. The voice was not who I thought it was. I turned around and it was someone else. The Activity Director was standing there laughing and I quickly said I'm sorry I thought you were someone else and hurried out of the room.

Locked In

I was doing my sanitation rounds in the kitchen at my facility this week. I was walking around looking at things and asking questions. I went into the dry storage and looked around. I went back out and checked the reach in cooler and asked where the freezer was. This was my first official sanitation rounds being new to the facility. The dietary aide said the walk in is in there. I trotted in opened the door and noticed there was a bar that moved but didn't pay much attention. The door closed. I started looking around making my notes. When I was done I went to the door and pushed. The door didn't budge. I pushed again, nothing. I noticed the bar and it was there to hold the door from closing. I guess I should have figured that out first. Well, I then began to panic. Of course I didn't have my cell phone. I beat on the door and screamed. No one came. I continued to freak out beating on the door. Well I started kicking the door and it finally popped opened. I was frozen and my throat hurt from screaming. I asked the dietary staff if they heard me. One guy said I heard you but when I went in you were coming out. When I told my friend who is also an administrator she said it would have been horrible if you died in there. No one could have kept a straight face at your funeral.

Compassion

Several years ago while working at a nursing home as the administrator the director of nursing died. The whole facility was devastated including the residents and staff. The work that we do is hard enough without something as traumatic as this occurring. This occurred on a Friday. On Monday we started having visits from the managers of other local facilities who brought cards and food for the staff. It was obvious that they had coordinated this because there was a different building and treat each day. As the week went by every nursing home in a 30 mile radius brought something to our facility. This goes to show that people who work in long term care regardless of competition for residents are loving caring people. We are all an extension of each other. I can't tell you how much this helped my facility get through this difficult time.

Nursing Home Humor

Never Say Never

It's funny how life often forces us to re-evaluate our goals. About 10 months ago I decided to step out of a permanent management position in long term care. I started looking for alternatives. I applied for numerous jobs for on line work, remote positions, hospital nursing, contacted former colleagues and finally was referred to a company that fills interim positions, consulting and mock surveys. Through this company I had the opportunity to work in assisted living, fill in as unit managers, directors of nursing, administrators and my favorite doing mock surveys. I enjoyed the work and was able to take time off when I wanted for how long I wanted. I have thoroughly enjoyed this. The problem is life sometimes gives us lemons so we have to make lemonade. My spouse developed a serious illness which has made my traveling job impossible for an indefinite amount of time. Well as he title states never say never, I left a permanent roll in long term care and now have the opportunity to go back and be the Administrator at a facility I spent about 10 years with. I never said I would never go back to a permanent roll or to that specific facility. I learned work ethic from my parents and learned to never burn bridges. I feel that this is what has allowed me to have the wonderful jobs and meet the great people I have. I hope to use what I have learned from my adventures to be a great leader. I m looking forward to where my career will care me next.

Cute Story

I have been covering as the administrator at a small nursing home for the past 3 weeks. I brought in items from home to use for national nursing home week. Today I decided to put the baskets in my car to take home. I put my purse and other things to take home in the basket and sat it down while I locked my door. In the mean time a resident was coming down the hall and casually looked at me and said "most executives use a brief case" and continued down the hall. I just laughed and gave her a hug. That made my day.

A Change of Role

I have been working as an independent contractor now for almost 6 months. I have had the opportunity to do mock surveys. I have completed the same tasks for facilities I worked for or were part of a company that I worked for, but doing it for a facility I am not an employee of is a little different. I really enjoy the process but also understand the stress it causes. I have had the opportunity to use the abaqis program and electronic records. This method makes the documentation review much easier. There is no trying to read someone's writing ( mine is horrible, I always felt sorry for surveyors trying to read it). The abaqis system mimics what the surveyors use exactly. During the first stage the system uses a computer program to choose the sample to be reviewed. Once this is done it guides you through a chart review that identifies trends that could be a deficiency. During the first stage you also complete interviews with residents, family and staff. Another part of the first stage includes direct observation of dinning, kitchen, medication pass and storage. once this is done it helps determine if additional information needs to be completed. This has been a positive experience for me. I love to teach and I use this process as an opportunity to share my knowledge during the survey as much as possible. I also get the opportunity to develop a plan of action for the facility to implement to correct the issues discovered during the process therefore sharing my knowledge and advice. I feel that facilities should self monitor as an ongoing process but should have someone not connected with the facility do a mock survey at least every other year if they have good survey outcomes and annually if they have problems or management turnover. Self monitoring can be skewed by staff and managers not being completely honest in order to look good on paper for a multitude of reasons:1. fear of what others will think of them,2. afraid of loosing their job, 3 not obtaining a bonus. If a facility cannot afford the abaqis program all of the forms can be printed directly from the CMS web site. Good survey outcomes will help a facility achieve a higher rating in the 5 star program resulting in improved census and community standing.