Preparing for the new survey process should not be much different than what you are already doing. Surveyors are just changing the way they look at things and viewing them more comprehensively than they did before. However, there are certain things you should be preparing weekly and monthly throughout the year in order to be ready for your survey.
Review Quality Measures
Quality Measures should be reviewed at least monthly, although you can get them from CASPER weekly by putting in the date from the last Monday in both the start and end date boxes in the report request. Be careful not to just review the “high” numbers. Sometimes low numbers which might seem positive may indicate selective MDS coding. Also, review those residents with multiple flags even if the particular flags are not an issue for the facility. These residents and the selected areas are more likely to be scrutinized during the survey process. Everyone should participate in this, not just the MDS coordinator or DNS.
Hold Weekly Standards Meetings
Some facilities call it a “risk” or “customer-at-risk” meeting. Whatever the title, this should be a meeting to review issues from the previous week as well as follow up on things like:
- Psychotropic medication use and the 14-day review requirement
- The 14-day review requirement for non-healing pressure ulcers
- Your Matrix, as well as your admission and discharge sheet for the survey entrance conference
- Grievance review
- Review of new admissions and baseline care plan completion
Have the team members responsible bring the actual documents to the meeting. You don’t want to find out that things weren’t completed prior to survey, so you want to check regularly that they are done.
By holding these meetings, you are more likely to catch areas that need improvement and maintain a high standard of care. Have your medical director, consultants, and vendors review meeting minutes to assist in problem identification. Make sure you document all staff that have been involved.
Hold yourself and your team accountable for review meetings. It is very easy in our crazy world to prioritize these meetings right out of our schedule. However, these meetings will help you find the issues first and address them before the surveyors are in your building.
Be sure to also include your staff development team member so that education of staff and review of new staff can take place promptly.
Prepare QAA/QAPI Documentation
Remember that everything you review and make plans to change or correct or follow up on can qualify as QAPI, so make sure you document these reviews and corrections to be added to your QAPI program. The members of your QAPI team need to review all the information (e.g. signing for review) to meet the new survey process requirements. We are hearing that facilities are getting deficiencies for lack of QAA committee meeting activities, so make sure you know the requirements and have the documentation to prove it.
A Few Final Tips
- Remove any unnecessary meetings or projects from your staff’s schedule so that they have adequate time to complete their daily tasks with accuracy. The standards meeting is important to keep but take a look at some of the other tasks you might be able to cut.
- Try to incorporate the new forms and survey process into what you are already doing and keep them updated. You will get much better compliance this way and much less duplication.
- Have staff from different departments assist with rounds to help identify issues. Fresh eyes are what you want. Surveyors often “see” things that cause them to investigate. Do these rounds when staff are the most distracted, around prime time for issues to arise.
The key is holding yourself and your team to these activities even when other issues come up. There will be plenty of stress once the survey starts so anything you can have prepared ahead of time will be one less thing to worry about.