Hi everybody! I am relatively new to my position as Clinical Educator/Infection Control at a LTC facility and we are in our window for state survey. I was told that the last survey at my facility was September 2016. How long is the window for state survey? Everybody says they will be here any day now but it is October 2017 and we are overdue for our annual. When is the deadline for survey to show up? I am nervous because this is my first survey where I am in an administrative position and want to get it over with. We had a G tag on infection control before I started my position and am afraid that the surveyors will target me. I value my job and am wondering if surveyors will be kind since I am new or if they will hang me out to dry. Please advise. Thank you!
The survey window is generally 9 - 15 months from your last survey. They will not be kind to you because you are new, they will also not "hang you out to dry" because you are new. They have a job to do just like all of us. Their goal is to ensure residents are free of harm. Remember - their goal is not to target YOU but the facility if they determine the facility is not keeping the residents free of harm.
Review your infection control plan of correction from last years survey and make sure every one of those t's are crossed and i's are dotted.
In Massachusetts, I've been told by surveyors that they can come any time they want for annual survey even if they go past the 15 months. They are staff challenged like the rest of us. Basically the surveyor said "We make the rules. We can change the rules." They walked in on the very last day of the 15 months since the last survey.
As for infection control, you know that startng in November, there is supposed to be someone in the building certified in Infection Prevention. The surveyors look for basics...wash your hands after you take off your gloves especially when doing a dressing change. Many nurses remember to change gloves after taking off the old dressing, but forget to wash their hands before putting on a new pair. It's the easy stuff they'll get you on.
They got us on a dirty shower chair this year, and then were upset about the location of our sinks and dirty utility rooms (that have been that way for 30 years!). Our CNA didn't wash her hands for a long enough time, and another one put a dirty brief on the bedside table. And our poor infection prevention nurse is going nuts about the antibiotic stewardship program we have to implement. They came the very last week "possible" where they would be out of compliance- due at the end of June and came in September. They also did a thing where they would send someone in the week before to take care of minor incidents to investigate to make survey shorter. Glad it's over! Good luck!
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