The director of nursing services (DNS) position is multi-faceted, and a new DNS must learn a lot quickly. Areas such as providing residents quality care and staffing take top priority, and rightfully so. However, another chief priority is on the DNS’s mind daily: survey. Poor survey outcomes can have negative effects such as civil money penalties, payment denials, and damage to the facility’s reputation in the community. Unfortunately, because there are so many requirements, there are also many opportunities to fall short. Staff look to the DNS to understand and clarify these requirements. For the new DNS, this responsibility can be daunting—complicating an already stressful process. This article will provide tips the new DNS can use to ease the survey process and help ensure it goes smoothly.
Prior to Survey
As the saying goes, “The best defense is a good offense.” This applies to the survey process as well. The more prepared a facility is ahead of the survey, the smoother it will go. The goal is to be survey-ready every day. The DNS can help the facility achieve this by following these tips.
- Know the survey process. The DNS should familiarize himself or herself with the survey process. The Centers for Medicare & Medicaid Services (CMS) outlines each step of the survey process in the Long Term Care Survey Process (LTCSP) Procedure Guide. The DNS can find this guide in the Survey Resources ZIP file, under the downloads section of the Nursing Homes, Quality, Safety & Oversight- Guidance to Laws & Regulations webpage.
- Don’t try to do everything at the same time. Instead, focus on one or two facility systems a month. Schedule a time to investigate compliance in-depth, using the Critical Element Pathways (also found in the Survey Resources ZIP file) surveyors will also apply. This approach, along with a review of associated policies and procedures, ensures a thorough examination of the facility’s system. Limiting that review to only one or two systems a month can prevent the task from becoming overwhelming. AAPACN has developed the Survey Readiness: Critical Element Pathways, Observations, Reviews, and Policy Calendar to assist with this review.
- Prepare staff. Surveyors observe and interview staff during surveys. The DNS should ensure that staff know how to answer questions regarding abuse, care plans, emergency preparedness, and the facility’s Quality Assurance and Performance Improvement (QAPI) program. Prepare staff for surveyors’ observations during procedures by having nursing leadership observe them during peri care and medication pass then offer constructive feedback and answer questions the staff member may have about the procedure. Preparing staff will ease anxiety about doing a procedure or answering a question wrong.
- Develop and maintain a survey binder. There are six designated time frames to deliver items to surveyors. The DNS can prepare many of these items in advance, while others must be gathered on the day of the survey. Having ready a binder, or some other type of system, that contains as many as possible of the items on the entrance conference worksheet will help the DNS respond when surveyors request them.
- Check in with the residents to ensure their satisfaction. Don’t assume all is well; ask residents if there are any issues the facility should address. Identifying areas that residents are dissatisfied with enables facility leadership to correct these issues prior to survey. Even if the resident later relays a problem to a surveyor, leadership can show what has been done to correct the issue.
AAPACN has developed the Survey Preparedness Program that adapts surveyors’ methods and tools to help the DNS facilitate activities throughout the year. By preparing the facility to withstand the scrutiny of the standard survey process, facilities can successfully demonstrate their compliance.
Once surveyors have entered the facility, it’s go time! If the DNS is prepared and knows what to expect, there’s no need to panic. By exhibiting calm, the DNS can help to reduce the anxiety other staff may experience. When the DNS is confident in the facility’s survey preparation, staff will feel they are ready, too. Although the process will inevitably inspire some nervousness, the DNS can use the following steps to lessen anxiety during the survey.
- Remember: this is a team event, and the DNS works with other departments and nurse leaders to ensure residents receive basic care and services throughout the survey. The nursing home administrator (NHA) will assign responsibilities for survey management tasks specific to observations and support of resident care. This will include rounds that confirm:
- hygiene needs (e.g., clean nails, hair combed) are met,
- fluids are within reach,
- call lights are within reach,
- assistive devices are functional and in place,
- resident rooms are neat and clean, and
- resident refrigerators are clean.
Prior to survey, the NHA and DNS should provide education to staff on survey management tasks. Cover what is expected for each task and who to contact when staff discover problems so that the facility can make corrections.
2. Check in with surveyors on a consistent basis to see if they need anything. This enables the DNS to answer surveyors’ questions or provide additional documents in a timely manner. However, before initiating contact with surveyors, check with the NHA. Often, the NHA will designate a point person for communication. This approach can help to avoid bothering surveyors, which may hamper their progress or frustrate them, and also ensures the facility provides consistent information.
3. Check in with staff frequently. Answer questions they may have during the survey. In addition to reassuring staff about the process, this is also the DNS’s opportunity to learn information such as what surveyors may have observed and questions they may have asked. If it emerges that a staff member may have answered a question incorrectly, speak to staff in a calm manner and work to correct the situation promptly.
4. Conduct an end-of-day meeting with nurse leadership. Often, surveyors will conduct a daily exit meeting with the administrator or the DNS. Once surveyors have left the facility for the day, review with the team any information from this exit meeting. Discuss what occurred during the day, issues that were addressed, and any issues that still need correction. Before leaving for the day, also check with the NHA to see if there are any outstanding documents that still need to be provided to surveyors.
5. Arrive early. The DNS and nursing leadership should be proactive and arrive each morning before the surveyors. Conduct rounds to ensure residents are cared for and the facility presents well. Additionally, confirm that no new issues arose since leaving the facility the previous evening. The DNS can use the AAPACN Daily Clinical Rounds Tool and the Weekly Medication Storage Tool to assist with these rounds. Correct any issues identified on these morning rounds.
Once the surveyors have completed all phases of the survey, they will conduct an exit conference. The DNS should take detailed notes during this conference to refer to later.
When the survey is over, the DNS should take a deep breath and reset for the next phase. While waiting to receive the Statement of Deficiencies (SOD) known as the 2567, the facility should begin correcting any deficient practices identified during the survey.
The state survey agency has 10 business days to send the SOD to the facility. Particularly if the facility receives a scope and severity of G or greater, it should start the plan of correction process as soon as possible. Review any notes from the exit conference and formulate corrective actions. Jumpstart implementation by prioritizing corrections, beginning with those deficiencies with the highest scope and severity. Then, once the SOD has been received and reviewed, execute the final plan of correction.
When reviewing the SOD, read it thoroughly to ensure understanding and identify any mistakes. Once that is completed, focus on implementing the plan of correction. Keep in mind the corrections already initiated and consider whether any require changes or removal. Work with the NHA to set reasonable completion dates. Give staff enough time to make corrections without taking too long. Complete corrections with enough time for resurvey; otherwise, the facility may be at risk for denial of payment. This can be a delicate balance, especially if the facility receives a deficiency with high scope and severity.
AAPACN has developed the F-Tag Library, an on-demand educational series of modules that provide an overview of each F-Tag and share steps to help the DNS attain and maintain compliance with the regulations. This series also includes presentations for newer leaders, such as guidance on how to understand a 2567, how to write a plan of correction, removal of Immediate Jeopardy, and understanding the Psychosocial Severity Guide.
Remember, it’s okay to get help. There are many resources available, and the DNS should use them. These resources may include:
- Management company nurse – This nurse knows the facility’s policies and procedures, as well as the regulations, and can help the DNS answer the survey team’s questions about facility practices.
- Corporate attorney – The attorney can assist the DNS with interpreting the regulations and how to discuss them with surveyors.
- Physician or nurse practitioner caring for residents – The physician or nurse practitioner can speak with the surveyor regarding the current treatment plan, why that plan is being utilized, any previous treatments that may have failed, and why.
- Vendor utilized for equipment or treatments – Vendors can discuss the parameters of use for equipment or treatments and why the selected approach was appropriate.
- Pharmacist – The pharmacist can elaborate on any medications that surveyors may have questions about.
- Dietitian – The dietitian can discuss dietary interventions implemented for a resident that surveyors may have questions about.
- Academic articles – The DNS can utilize academic articles to obtain clinical evidence that guides care.
Survey is a very stressful time for all involved, especially a new DNS. However, if the DNS utilizes the above strategies are, the process will go a little smoother. With preparation, the anxiety will be less for all, while survey outcomes will be more positive.
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