"State's Here!": Demystifying the Long-Term Care Survey

Everybody dreads it: that morning when a group of official-looking people walks into their facility and announces the beginning of the annual survey. Here are a few clues as to how to help make yours go smoothly, what surveyors are looking for, and why we do what we do. Specialties Geriatric Article

"State's Here!": Demystifying the Long-Term Care Survey

It's the same every year: a contingent from "The State" invades your facility and commences with scrutinizing your work, poring over your records, nosing around the kitchen and dining areas, and asking endless questions. Managers who are rarely seen outside their offices suddenly become helpful, wiping down dining tables and pushing wheelchairs, while everyone from charge nurses to housekeepers strive not to show their nervousness as surveyors watch them perform their duties.

I know it seems as though we are only there to catch you making mistakes and taking poor care of your residents. I was on the receiving end of state surveys for years, so I can empathize with you and understand how it feels to have State in your building. Here are some tips from a nurse who went over to the "dark side" that may help you cope during your next one.

We are not there to intimidate you

In fact, newer surveyors are taught specifically NOT to be aggressive or make people feel bad. Respect and cooperation between surveyors and staff is the best way to accomplish our mutual goal of providing quality care to residents.

We are not there to "dig up the dirt"

However, we do have a job to do, and that is to assure that residents are being treated with the care they deserve, as well as enforce the regulations governing that care. If your facility receives a few citations, it's not because we think you're terrible, it's because we've found deficient practices which are not in accordance with the CFRs (Code of Federal Regulations). And in case you're wondering, we don't make these up as we go along; we are bound by strict rules to be factual and objective in citing deficiencies.

Here are some of the things we look at when we visit you

Obviously, we're going to pay a lot of attention to nursing and related services, and the emphasis often changes. For example, right now we're focusing on unnecessary medications and antipsychotic use in dementia patients; while a few years ago, it was use of alarms and restraint reduction. We will also review sanitation, make observations of the dining experience, work with the fire marshal on fire and life safety, and ensure that resident funds are being managed properly and that employees of the facility have had background checks done.

"Just the facts, ma'am"

If you are interviewed by a surveyor, try not to let emotion get the better of you. We know you're nervous, but we didn't pick you because we suspect you of anything; we need information that only you, and perhaps a few of your co-workers, can give us. It will take less of your time if you just answer our questions rather than volunteer your opinion of a given situation. The exception to this is when you are aware of a deficient practice and nothing was done to correct it when you reported it to your supervisors; even then, we'll probably ask you only the who, what, when, where, and why.

We can't fix the facility's problems

Sometimes we will offer technical assistance in the case of an issue that needs to be addressed, but doesn't quite rise to the level of a citation. Otherwise, we are not permitted to advise a facility on how to comply with the CFRs; it's not our job to tell you what you need to do to correct deficiencies or how to deal with staff members who may have committed errors that drew our attention to a specific area of concern.

For managers: Please make sure that all MDS assessments are coded correctly and submitted in a timely fashion

If this most basic element isn't done right, it will require us to look further into your documentation systems. 'Nuff said.

And lastly.....

A surveyor with a tablet computer in her hand is not your enemy

Believe it or not, we're on the same side---we ALL want SNF patients and LTC residents to receive the best possible care. Yes, we know it can be overwhelming to do a med pass with someone standing next to you and watching your every move. It's nerve-wracking to do peri-care on a resident while a surveyor stands on the other side of the bed taking notes. Just remember that most of us have been there ourselves, and we know exactly how it feels.

In future articles I'll discuss more in-depth the Quality Indicator Survey (QIS) and how it differs from the traditional survey process, as well as the care areas that tend to draw the most scrutiny from surveyors.

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VivaLasViejas

About VivaLasViejas, ASN, RN

Long Term Care Columnist / Guide

I'm a Registered Nurse and writer who, in better times, has enjoyed a busy and varied career which includes stints as a Med/Surg floor nurse, a director of nursing, a nurse consultant, and an assistant administrator. And when I'm not working as a nurse, I'm writing about nursing right here at allnurses.com and putting together the chapters for a future book about---what else?---nursing.

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Specializes in Gerontology, Med surg, Home Health.

I disagree 100%. Surveyors love to intimidate any staff membee they can. They are rude, condescending, and demeaning. They try to twist what staff members say and they misquote us when they write out the SOD.

YOU might not be that kind if surveyor, but most, if not all, of the ones I've dealt with over the years have been awful.

I would like to take the "committee" that made restraints such as lap buddies and table top trays for non-ambulatory patients illegal, put them in a barrel and send them over Niagra Falls. Then I would ask them, "how does it feel to break every bone in your body."

It's the same every year: a contingent from "The State" invades your facility and commences with scrutinizing your work, poring over your records, nosing around the kitchen and dining areas, and asking endless questions. Managers who are rarely seen outside their offices suddenly become helpful, wiping down dining tables and pushing wheelchairs, while everyone from charge nurses to housekeepers strive not to show their nervousness as surveyors watch them perform their duties.

I know it seems as though we are only there to catch you making mistakes and taking poor care of your residents. I was on the receiving end of state surveys for years, so I can empathize with you and understand how it feels to have State in your building. Here are some tips from a nurse who went over to the "dark side" that may help you cope during your next one.

1) We are not there to intimidate you.

In fact, newer surveyors are taught specifically NOT to be aggressive or make people feel bad. Respect and cooperation between surveyors and staff is the best way to accomplish our mutual goal of providing quality care to residents.

2) We are not there to "dig up the dirt".

However, we do have a job to do, and that is to assure that residents are being treated with the care they deserve, as well as enforce the regulations governing that care. If your facility receives a few citations, it's not because we think you're terrible, it's because we've found deficient practices which are not in accordance with the CFRs (Code of Federal Regulations). And in case you're wondering, we don't make these up as we go along; we are bound by strict rules to be factual and objective in citing deficiencies.

3) Here are some of the things we look at when we visit you.

Obviously, we're going to pay a lot of attention to nursing and related services, and the emphasis often changes. For example, right now we're focusing on unnecessary medications and antipsychotic use in dementia patients; while a few years ago, it was use of alarms and restraint reduction. We will also review sanitation, make observations of the dining experience, work with the fire marshal on fire and life safety, and ensure that resident funds are being managed properly and that employees of the facility have had background checks done.

4) "Just the facts, ma'am".

If you are interviewed by a surveyor, try not to let emotion get the better of you. We know you're nervous, but we didn't pick you because we suspect you of anything; we need information that only you, and perhaps a few of your co-workers, can give us. It will take less of your time if you just answer our questions rather than volunteer your opinion of a given situation. The exception to this is when you are aware of a deficient practice and nothing was done to correct it when you reported it to your supervisors; even then, we'll probably ask you only the who, what, when, where, and why.

5) We can't fix the facility's problems.

Sometimes we will offer technical assistance in the case of an issue that needs to be addressed, but doesn't quite rise to the level of a citation. Otherwise, we are not permitted to advise a facility on how to comply with the CFRs; it's not our job to tell you what you need to do to correct deficiencies or how to deal with staff members who may have committed errors that drew our attention to a specific area of concern.

6) For managers: Please make sure that all MDS assessments are coded correctly and submitted in a timely fashion.

If this most basic element isn't done right, it will require us to look further into your documentation systems. 'Nuff said.

And lastly.....

7) A surveyor with a tablet computer in her hand is not your enemy.

Believe it or not, we're on the same side---we ALL want SNF patients and LTC residents to receive the best possible care. Yes, we know it can be overwhelming to do a med pass with someone standing next to you and watching your every move. It's nerve-wracking to do peri-care on a resident while a surveyor stands on the other side of the bed taking notes. Just remember that most of us have been there ourselves, and we know exactly how it feels.

In future articles I'll discuss more in-depth the Quality Indicator Survey (QIS) and how it differs from the traditional survey process, as well as the care areas that tend to draw the most scrutiny from surveyors.

Great overview.

I'll keep this in mind. thanks.

Specializes in Home Health.

Our facility is currently waiting for "the visit." I'm a recent transfer from a sister facility that only had 3 def and only one in Nursing. Now 2 months later I'm dealing with another facilities major issues. Our administrator left and now we have the "interim" who, I'm told came to fix things. We've lost 4 nurses since I started on Dec 26, 2014. The CNA revolving door is still swinging. The MARS here are a mess. This article makes me feel a little more at ease but I fear I will be interigated on residents I don't really know since they never schedule me in the same place.

Specializes in Multiple.

I haven't worked in LTC in 6 years, but this title gave me temporary anxiety. It's never quite as scary when the DOH comes by. At least in Minnesota, the suveyors are quite nice and helpful.

I am a newbie LPN...graduated in May and started my first job at the LTC facility I'm at in October. I work infrequently- two to four shifts a month PRN, because 1) the facility is pretty well staffed for nurses and I was hired at the back end of a crop of PRNs that get first crack at shifts before I do, and 2) I am in school for my associate's and really can't afford to work more than I do.

I went by work today to pick up my paycheck, and there was a notice on the door stating that a state survey was occuring until February 14th. My stomach turned. I had fervently hoped that there would be no survey until I had been there a few more months and was more comfortable in my job and more knowledgeable. I work juuuuust little enough to feel lost and clueless every time I DO work. Don;t get me wrong- I still play it safe and ask ask ask questions or for help with anything at all I am not sure about.

Anyhoo...this Thursday night is my first solo night shift, and I have only oriented on nights two times. I didn't really feel prepared to tackle Thursday night's shift in the first place, but now with state here, I am freaking TERRIFIED. I know a lot of people say that state doesn't stay for night shift, but I know that's not a carved in stone rule, and a coworker told me that night before last they stayed til like 9pm or so.

I just worry that I will inadvertently do or say something wrong to get myself or the facility in trouble. I am one of those people that gets all spazzed out when I know I'm being watched and evaluated. Like in nursing school during skills check-offs- I was a nervous wreck every time, but during practice I was fine.

I just wish I could call off or even that the DON would call me and say "I know you're still very new and we'd be more comfortable having one of the more experienced nurses come in that night." My feelings wouldn't be hurt at ALL!!

Specializes in LTC,Hospice/palliative care,acute care.

Something I have learned and would like to add is NEVER answer a question from a surveyor with "I don't know". If you really don't have the answer just be honest and tell them so and tell them you know where to find it and get back to them after you do.

Offer them a cup of nurse coffee.A little of that goes along way. I have dealt with a few who seemed to want to abuse their power and intimidate but they truly have been the exception (except for a former DON from another area home-but she never was what I would call 'nice" She always looks like she smells something bad or licked something very sour)

Specializes in LTC,Hospice/palliative care,acute care.

[quote=pinkiepinkPN1;7747825

I went by work today to pick up my paycheck, and there was a notice on the door stating that a state survey was occuring until February 14th. My stomach turned. I had fervently hoped that there would be no survey until I had been there a few more months and was more comfortable in my job and more knowledgeable. I work juuuuust little enough to feel lost and clueless every time I DO work. Don;t get me wrong- I still play it safe and ask ask ask questions or for help with anything at all I am not sure about.

QUOTE] Pink, just breathe. Remember the rights of med admin (especially privacy) and wash your hands, wash your hands, wash your hands. And glove,glove, glove. If you are being observed during a med pass don't feel compelled to make small talk, that will lead to problems. If they talk to you, stop what you are doing, answer the question and then breathe and continue. I can't stress enough how important that is-just breathe.Slow and deeply-it does help you relax and stay focused.That said,as long as I've been in the game I will still become a sweaty ,mumbling mess if I don't concentrate and breathe.

It's better you be exposed to the process now then dread it for the next 10 years. It does get easier as you gain more confidence in your skills.

Specializes in Multiple.

I was always told that they need to see at least every shift. Does that mean they stay until 6 am? No, but someone usually stays until a little after 10 pm.

Viva, you may be that type of surveyor, but most that I have met are unpleasant and think they "walk on water." They are condescending and think that you have all the time in the world to wait for them to get ready to observe whatever they want to observe, don't care that you may have to do multiple other things rather than wait on them. I was agency in a facility and was quizzed by a surveyor about facility policies despite the fact that it was my first time there. I could go on.....

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