“Why in the world did my staff member say this?” and “Why did my staff do that?” are two questions that no director of nursing services (DNS) wants to have when reading the Statement of Deficiencies and Plan of Correction (form CMS-2567) handed out by the state survey team at the end of a standard survey, points out Denise Winzeler, BSN, RN, LNHA, DNS-MT, QCP-MT, a curriculum development specialist for AAPACN.
“Reading what your staff have said or done can be shocking when it doesn’t align with the education that you have provided to them,” acknowledges Winzeler. “However, these surprises can—and do—occur when there is an inadequate focus on staff during survey preparation. Residents and documentation are two key components of survey preparation, but to fully mitigate your survey risks, staff education and preparation is critical.”
To prevent survey surprises, the DNS must transition survey preparation away from a reactive approach and implement a proactive process, suggests Winzeler, who will present the April 11 session “Taking the Surprise Out of Survey Results: How to Prepare Staff for Survey” at the AAPACN 2024 Conference, which will take place April 10 – 13 in Hollywood, FL.
Winzeler offers the following tips that can help the DNS be more proactive with staff survey preparation:
Schedule year-round survey preparation activities
Limiting survey preparation to the period just before the facility’s survey window opens increases the risk of poor survey outcomes, says Winzeler. “Survey preparation shouldn’t have start and stop dates. You and your team should be preparing year-round.”
AAPACN made it easier for the DNS to understand what to schedule when and to track completion of each survey preparation activity by developing a planning tool: the Survey Readiness: Critical Element Pathways, Observations, Reviews, and Policy Calendar, notes Winzeler. “This is a fantastic tool that I will be sharing and discussing during my conference session. Implementing it will help you make survey preparation systematic.”
The basic concept of the tool is to guide the DNS through putting survey preparation into a month-by-month calendar format, explains Winzeler. “It uses a sample calendar to demonstrate how you might want to schedule the various components. For example, you could focus on the facility assessment in January and infection prevention and control and immunizations in February.”
In addition, this planning calendar indicates key areas of focus for each component of survey preparation, says Winzeler. “For example, it shows which critical element pathway or other survey tool the survey team will use to investigate that component, as well as which facility policies and procedures may need to be reviewed.”
Organized survey preparation will help the DNS and the management team identify and address systems issues more timely, notes Winzeler. “The results of those reviews also will lay the groundwork for how you will educate your staff. So, this is a wonderful tool that ties together multiple areas of survey preparation for you and your team.”
Note: AAPACN’s Survey Preparedness Program also includes complementary resources and tools that can assist with survey preparedness.
Educate with a consistent message across multiple formats
Two educational principles that the DNS needs to understand are as follows, according to Winzeler:
- Everyone learns differently. “Some people learn well by reading; others can learn by watching videos; and still others learn by doing,” explains Winzeler. “The staff development nurse or whoever is in charge of educating your staff must know how those staff members take in that education and learn best. Then, you can tailor the staff education to their learning needs.”
- Repetition is critical. “One of the building blocks of communication theory is that a person may need to hear something up to seven times before it embeds in their memory,” says Winzeler. “So, for example, providing one in-service or one computer-based training program and then moving on isn’t a strong approach. You need to provide a consistent message that is conveyed multiple times in multiple ways so that your staff actually comprehend that message and can put it into practice.”
The DNS should work with staff development and the entire leadership team to develop strong educational channels, suggests Winzeler. “One option for hands-on learning is to do mock drills. Everyone does elopement drills and fire drills, but you may want to consider doing other types of drills, such as a substance use overdose drill, a post-fall drill, or a resident-to-resident altercation drill.”
Other educational options include lectures, case studies, and group trainings, says Winzeler. “The DNS and other nurse managers also play an especially important role with one-on-one just-in-time trainings. When you are doing rounds and see a staff member doing something incorrectly, such as hand hygiene, you need to stop and do some individualized education with them to re-enforce facility policy and procedure. That is key.”
One aspect of staff education that often is overlooked is how to prepare for survey nervousness, says Winzeler. “Staff often get nervous around surveyors, especially when they are being observed, for example, during a medication pass or peri-care. During my session, we will review how you can educate your staff to manage those nerves so that they can perform as well in front of a surveyor as they normally do during their daily practice.”
For example, one technique is to have staff perform their competencies in front of other people throughout year, says Winzeler. “Once a staff member becomes used to performing a task in front of others, then it doesn’t matter who is there watching because they will do it the same way every time.”
Agency staff need to be considered as well, says Winzeler. “Many providers have to use agency staff in the current staffing environment. Surveyors often do a lot of observations of agency staff, and they usually ask agency staff almost as many questions as they do facility staff. My session will cover how to incorporate agency staff into your staff survey preparation. You cannot leave them out if you want to be proactive.”
Note: See F-tag 726 (Competent Nursing Staff) in Appendix PP of the State Operations Manual for details on education and competency requirements for all nursing staff.
Manage through the survey
Staff education should not stop as soon as the surveyors walk in the nursing home, says Winzeler. “You can’t let the survey manage you. You have to manage the survey so that you can take advantage of opportunities for mitigation.”
A critical part of survey management is leadership being out on the floor and finding out what is happening, explains Winzeler. “If you know what the surveyors are looking at, you then can educate your staff in real time—and you can be sure that they will respond to the surveyors in the manner that they should.”
For example, if the survey team is targeting pressure ulcers, the DNS can use the staff interview questions on the Pressure Ulcer/Injury Critical Element Pathway (form CMS-20078) to boost staff confidence in a pressure-filled situation, suggests Winzeler. “You can question your staff, ‘If one of the surveyors comes up and asks you this question, how will you answer them?’ During my session, we will take a deeper look at survey management in addition to survey preparation.”
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