The Dreaded Mandatory Survey Task: Sufficient and Competent Nurse Staffing

By Amy Stewart, RN, DNS-MT, QCP-MT, RAC-MT - January 10, 2018

Mandatory and facility-level tasks and what they mean for your next survey

With the new survey process, surveyors will walk into your facility and get right to work. They will use the first 8–10 hours to complete the initial pooling process, in which each surveyor conducts short observations, interviews, and limited chart reviews in order to select about eight residents for possible inclusion in the resident sample. Once the surveyors have the complete initial pool of residents, they will select some of these residents to include in the sample selection. Surveyors will use the sample selection of residents to conduct a more in-depth investigation in areas of identified concern; this may include one or more of the mandatory task areas.

Surveyors conduct both mandatory tasks and facility-triggered tasks. Mandatory tasks are evaluated at every facility. (The mandatory task process, because it is adapted from the Quality Indicator Survey [QIS] process, may be familiar to directors of nursing services [DNSs] who have worked in QIS states.) Facility-triggered tasks may be evaluated at your facility, depending on whether there was a concern that triggered for one of the three task areas (Environment, Personal Funds, Resident Assessment), but they are not mandatory unless triggered. All mandatory tasks have a review sheet, which has been updated for the new survey process. Depending on the task, there may be one or more survey team members assigned. For the Sufficient and Competent Nurse Staffing Review task, which this article will discuss at length, all surveyors participate in the observation process.

Here’s the full list of mandatory tasks:

                      Beneficiary Protection Notification Review—Three randomly selected residents will be reviewed from the list provided by facility staff.

                      Dining Observation—All surveyors participate in the dining observation for the first full meal. The team may also conduct a second review if concerns were identified.

                      Infection Control—All surveyors observe for breaks in infection control during the survey. They also review the antibiotic stewardship program and the influenza and pneumococcal vaccinations.

                      Kitchen Observation—A brief kitchen visit is conducted on day one and ongoing observations are made during the survey.

                      Medication Administration—Observation of different medication administration routes, typically conducted by surveyors who are nurses or pharmacists. Observation of 25 medication opportunities, including whether the administered medication is expired. Handwashing is also a concern of the observation.

                      Medication Storage—Review of half of the medication storage rooms on different units. Review of half of the medication carts on units where storage rooms were not observed.

                      Resident Council Meeting—Typically conducted on day two of the survey. Interviews with active members of the resident council are conducted, along with review of council minutes if the council president gives permission.

                      Sufficient and Competent Nurse Staffing—Throughout the survey the survey team will be considering whether concerns with staffing can be linked to resident complaints or quality-of-life-and-care concerns.

                      QAA/QAPI—This task takes place at the end of the survey. Before surveyors review the QAA program, they will review facility rates for the MDS indicators, prior survey history, FRIs, and complaints to remind them of present and repeat deficiencies. Surveyors will also review the QAPI plan.

Here are the facility-triggered tasks:

                      Environment—This review is completed when there are environment-related concerns identified with sampled residents.

                      Personal Funds—This review is completed when there are identified concerns with sampled residents’ not having access to funds or not receiving quarterly statements.

                      Resident Assessment—This review is completed if there are concerns with a delay in completion and/or submission of MDS assessments or MDS discrepancies for care areas that weren’t marked for further investigation.    

Preparing your facility staff for the Sufficient and Competent Nurse Staffing Review mandatory task

So how can you prepare your facility for mandatory tasks, specifically, Sufficient and Competent Nurse Staffing Review? The review sheet, which guides surveyors through three levels of review—observations, interviews, and record review—can also be your guide as you prepare for survey.

The observations section clearly indicates what surveyors will be looking for. For example:

·         If mid-morning (e.g., 9–11 a.m.) or later, are residents still in bed and not dressed?

·         Are residents sitting around the nurse’s station, in the hallways, or in front of the television without any interaction from staff?

·         Are call lights and alarms responded to timely?

·         Are residents displaying behavioral or pain concerns such as being combative, yelling, or crying out?

The interview section lists questions that may be asked of residents, resident representatives, or family members; nursing aides and licensed nurses; and the DNS and staff development coordinator.

The record review section lists how surveyors will follow up if necessary on the first two sections.

To prepare, DNSs should review the Sufficient and Competent Nurse Staffing review sheet thoroughly. Look closely at the observations section. Is there anything listed that happens in your facility, even if only infrequently? If so, communicate the issue to staff and develop a plan to prevent it.

Next, review the interviews section to understand the number and types of questions that may be asked of various representatives. While you should communicate the questions to your residents and staff in advance of survey so that they are aware of and understand the process, this shouldn’t be your only preparation. The review sheet should also be used to identify problems beforehand so that you can put a plan of correction into action. The following interview questions, taken from the review sheet, serve as examples (note that these are only partial lists):

For residents:

·         Do you get your medications on time? This is a question that you should know the answer to before the resident is ever asked. Do you know for certain that medications are delivered on time, or are there regular delays? Perhaps there is a specific time of day when the largest quantity of medications are administered, which delays the delivery of medications for some residents. Or the nurse giving medications may frequently be interrupted by other tasks, difficult residents, or something else.

·         Do you receive medications that make you sleepy, tired, lethargic, or sedated? You should be getting feedback regularly from residents on their plan of care. It’s possible that a resident who isn’t familiar with what medications she takes and why (“I just take what they give me”) might answer yes, that her medications make her tired, when in fact none of her medications produces those side effects.  

·         Do you routinely eat in your room? If so, is this your choice and if needed, is assistance provided to help you? Are room trays delivered timely? If you have a resident who routinely eats in his room, make a renewed effort to invite him to the dining room to make sure he feels included. If he continues to choose to eat in his room, be sure that his food is delivered timely, not too early or late.

·         Are you able to wake, dress, eat, or engage in other activities at times that are preferable to you? Again, residents should be engaged in their plan of care. Do you know for certain that wake-up times are determined by resident preferences? Does your staff know that, or do staff members just go through the motions with the schedule, unaware that it’s driven by resident choice? Can your staff make a renewed effort to ask residents about wake times, food preferences, and activities? Residents, like all of us, can have changing preferences.

·         Do you think the nursing staff are experienced and knowledgeable when providing your care? If not, what concerns have you experienced? Do you know for a fact that your staff has the experience to confidently care for residents? Or do you know that some staff members, while they have the qualifications, are uncomfortable with specific tasks that they may not perform frequently? How can you better train and prepare your staff in these areas?

·         Do you recall a time when you didn’t feel well? Did you tell a staff member? What happened? For example, did you get better or worse? You know if any residents were recently ill. Talk about their experience with them and ask them how they felt the care response was. This will give them an opportunity to discuss the situation with you, and provide negative feedback, before the surveyor comes.

For staff:

·         How many residents are you responsible for on a regular basis during your shift? You know the nurse-to-resident ratio in your facility, but are your nurses often caring for more residents than they should because of call-offs, new residents, or something else? Are there enough staff members to meet residents’ needs and respond to changes in their care plans?

·         Do you have enough time to complete your required assignments each day? If not, why not, and what assignments are you not able to complete? How often does this occur? Do you really know how your staff members will respond to this question and how they feel about their responsibilities? When was the last time you checked with them, and could you make a more regular effort to do so, perhaps even on every shift?

·         Do you use position-change alarms? Why? Do staff members know to attempt other interventions prior to a position-change alarm? Would an in-service demonstrating all possible alternatives be helpful in advance of survey?

·         How are current staffing needs determined? Does management ask for your input into their facility assessment for sufficient staffing? If so, can you provide some examples of what you provided and if you know whether or not these were considered? How much did you engage your staff when determining staffing needs and conducting the facility assessment? Are staff members aware of the facility assessment, how it’s conducted, and what it’s used for? Do they know how their input was used to help determine staffing levels, or could that be communicated more clearly?

·         How are you made aware of the care and services the residents require as directed in their plan of care and what their individual choices are? How are these communicated to nurses, and how often?

·         How do you identify a resident’s change in condition? Can you provide some examples? When was the last time you had an in-service on changes in condition? Should you conduct one and practice this question in advance of the next survey?

There’s a lot to consider when it comes to each mandatory task. The key to success is to be proactive and avoid surprise: know what the task is, what surveyors will be looking for, and what will be asked. Don’t assume that residents or staff will know how to respond perfectly, and even if you prep them, don’t assume a resident or staff member won’t be having an “off” day. As a DNS, you can’t control everything, but you can prepare. The review sheet is an excellent tool to help you do so.

Often, as young students, we were given review sheets before an exam. The review sheets for mandatory tasks are CMS’s way of saying: This is what’s going to be on the exam. Get ready for it.

Note: This article is the first in a series that will explore how to prepare for specific mandatory tasks.


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  • Re: The Dreaded Mandatory Survey Task: Sufficient and Competent Nurse Staffing

    Very useful information. I am currently experiencing the new survey process. This has provided guidance as to what they are looking at and will better prepare my other facilities for survey.

    By: Dana on 01/11/2018 06:13:36 PM

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