DNS Starter Kit

Being new to the Director of Nursing Services role can be overwhelming, to say the least. Not to worry. AADNS was created with you in mind. We understand how much there is to learn as a new DNS, and we want to help you get up to speed, fast! The information and tips below will provide you with introductions to some of the most critical and complex components of your role, to help you on your journey to successful nursing leadership and to help your facility thrive.  


"Skilled nursing facilities (SNFs) and nursing facilities (NFs) are required to be in compliance with the requirements in chapter 42, Part 483, Subpart B, of the code of federal regulations to receive payment under the Medicare or Medicaid programs.  To certify a SNF or NF, a state surveyor completes at least a Life Safety Code (LSC) survey, and a Standard Survey (or a Quality Indicator Survey [QIS] if you are in a QIS state). SNF/NF surveys are not announced to the facility.  States conduct standard surveys and complete them on consecutive workdays, whenever possible."

Read the complete CMS source document here.  

Quick How To: When was your last federal survey conducted? The next survey could occur between 9 and 15 months after the previous one. To prepare, first ask the administrator to provide you with a copy of the CMS Form 2567 with the submitted plan of correction. Look at what deficiencies were issued and the specifics of the submitted plan of correction from the last survey. The plan of correction is the actions that the facility staff took and will continue to take to come into compliance with federal regulations for participation in the Medicare and Medicaid programs. Then, open Appendix PP of the State Operations Manual and look up the deficiencies for which your facility was cited.

In order to receive a five-star rating for staffing on Nursing Home Compare, a facility must be staffed at a minimum of 0.710 hours per resident per day with RNs and administrative nurses, and 4.418 hours with total nursing, which includes RNs, LPNs, and nursing assistants. On top of this pressure, Payroll-Based Journal requirements for transparent staffing levels take effect July 1, 2016. With both of these demands, and the need to implement staffing models that meet your residents’ needs, having a staffing plan is more important than ever. Every DNS must know and apply the five components of effective staffing, which include hours per patient day (HPPD), staff-to-resident ratios, resident acuity, and average wage, in order to implement the correct model for his or her facility.

Quick How-To: Find out from your administrator what are your department’s budgeted hours per resident per day and what adjustments to your staffing levels you can make as the census increases and decreases. Also, ask your administrator what staffing considerations are made to accommodate levels of acuity based on the residents that your organization cares for. Lastly, find out what your department’s turnover rate is and what measures are in place to reduce staffing turnover.

"The Traditional Nursing Home Survey refers to the original paper-based survey protocol that has been in use in various versions of the current form since its inception in 1995. The Traditional survey employs a 2-phased process. In the Traditional survey sample, surveyors use the survey protocol in the State Operations Manual to identify the number of residents to review (e.g., 18 residents in 100 bed facility), but have discretion in selecting the sample of residents to evaluate, allocating survey time, investigating potentially deficient practices observed during the survey, and determining what evidence is needed to identify a deficient practice. The post-survey data that is available to CMS consists of hours spent on the survey and the Statement of Deficiencies (i.e., CMS 2567 form). "

Read the complete CMS source document here.  

Quick How To: If your state uses the Traditional Survey method, find out more here.

"The Quality Indicator Survey (QIS) is a computer assisted long term care survey process used by selected State Survey Agencies and CMS to determine if Medicare and Medicaid certified nursing homes meet the Federal requirements. The QIS is a two-staged process used by surveyors to systematically review specific nursing home requirements and objectively investigate any regulatory areas that are triggered. Although the survey process has been revised under the QIS, the Federal regulations and interpretive guidance remain unchanged. The QIS uses customized software on tablet personal computers (PCs) to guide surveyors through a structured investigation."

Read the complete CMS source document here.

Quick How To: Find out if the surveys conducted in your state are based on the Traditional Survey method or the Quality Indicator Survey (QIS) method. To find out which type of survey your state survey agency uses, click on the map here. If your state uses the QIS survey method, find out more here.

"CMS created the Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily. The Nursing Home Compare Web site features a quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average. The Five-Star Quality Rating System Technical Users' Guide provides in-depth descriptions of the ratings and the methods used to calculate them."

Read the complete CMS source document here.

Quick How To: Find your nursing home's star rating for Overall, Survey, Staffing, and QMs on Nursing Home Compare. This will let you know how your facility is being represented to your community.

"Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care."

Read the complete CMS source document here.

Quick How To: Ask your MDS nurse to download the current QM reports from the CASPER online system. To see a sample of the CASPER QM report, click here. When comparing your facility's Nursing Home Compare ratings with the CASPER reports, you'll see that the scores will vary. This is because these two reporting systems use different time frames. Take note if your CASPER report scores are better or worse than the Nursing Home Compare scores. These two reports will help you prioritize the facility's nursing systems on which to focus quality improvement activities.

"QAPI is a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes. The activities of QAPI involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions."

At the core of QAPI is root-cause analysis (RCA), a process-analysis method that can be used to identify the factors that cause adverse events.

Read the complete CMS source document here.

Quick How To: Ask your administrator to discuss the facility’s Quality Assessment and Performance Improvement program with you. Since the prevention and management of pressure ulcers is an ongoing interdisciplinary focus, use this issue to learn about the facility’s systems and processes for identifying QA/PI priorities against benchmarks and to learn how the IDT goes about data collection, reviews results, plans evidence-based action for improvement, and monitors systems to achieve desired results. Understanding the facility’s approach to QAPI will help you to be an effective nurse leader on the interdisciplinary quality improvement team.