Survey Preparation

Dec 15, 2007 09:37 AM written by mercy1975 | 9 Comments

Here's some items that should be inserviced before your upcoming survey. These are alot of the areas the surveyors will be reviewing.

All staff to wear name tags

Greet and smile at surveyors as appropriate. They are guests in the facility and should be treated as guests. Offer water and coffee after breakfast is done.

Call residents by their names only

Nembulizers-include cleaning procedure

Inhalers-include cleaning procedure. Remind staff to shake the inhaler in-between puffs and offer water for resident to rinse mouth out.

Accucheck machine-clean after every use!!

Eye Drops-if giving multiple eye drops, know how long to go in-between giving them

Injections

Peri-care--try to have two staff go together. They can coach each other. Keep residents appropriately covered during intimate procedures.

Emptying of Foley bags

Tube medications-Do each med separately and flush between each med

Med pass- remind staff to use hand gel every time after giving a resident’s meds. Wash hands with soap and water after every 5th resident.

Policy and Procedure for Cleaning Razors

Positioning of residents

All residents to receive appropriate cueing and assistance during meals.

Keep all hazardous items locked up

All residents to be appropriate dressed

Man shaved by 10am

If wheeling a resident in a w/c their leg extensions must be on and feet appropriately placed.

All O2 tubing should be in a plastic bag and not laying on the floor.

Keep clean and dirty items separated by three feet minimum.

All staff to know where the care plans are located.

mercy1975 · Dec 15, 2007, 09:50 AM

Following is a listing of what should be included in a Survey Entrance Manual.

This is the information the surveyors will request upon entering into your facility.This will make the entrance go very well. This also will give the DON more time to be with the nursing staff instead of rushing to get the nursing information. This will save the surveyors time also which keeps them happy.Surveyors have been very impressed when this information is readily available.

1. Resident Roster with room numbers
2. Blank 24 hour report sheet with residents names (one for each surveyor)
3. List of key personnel, including the Pharmacy consultant and QA person
4. Copy of facility layout-(one for each surveyor)
5. Resident’s Advocate Committee names
6. HCFA Form 672
7. Work schedule for RN/LPN (day of entrance)
8. HCFA 802-up to date
Under “Wt.” Indicate with an arrow if weight is up or down
Under “UTI/ inf control/antibiotic”-note UTIs
Under “Interview able: Indiv/Fam” ,note With an “I” if the resident is
interview able. A list would be also be acceptable.
Under “Psychoactive Meds” note :“P” for psychoactive, “A” for
anti-anxiety, and “H” for hypnotic.
9. Policy /procedure for monitoring accidents/incidents and system to
prevent/minimize
10. Immunization practices (flu and pneumococcal)
11. List of employees since last survey (list position and hire date)
12. Admissions (past 30 days)
13. List of discharges (during last three months)
14. Medicare residents requesting demand billing (during past 6 months)
15. Resident age 55 and younger
16. Meal times (of all dining rooms)
17. Dining room seating chart- (one for each surveyor)
18. Copy of menus (including therapeutic menus for duration of the survey)
19. List of residents on therapeutic and mechanically altered diets
20. Work schedule for LPN/RN (Day of entrance)
21. Medication pass times for inhalers, eye drops, injections, g-tube
medications, and nembulizers.
22. Emergency water supply policy and procedure (5 gallons per resident per day)
23. CLIA wavier certificate
24. Copy of Surety Bond
25. Resident Rights
26. Admission agreement
27. Policies /procedures to prohibit /investigate abuse
28. Activity calendar (last three months)
29. Resident Advocate Members
30. Resident council meeting minutes-(last three months)

**VivaLasViejas** · Dec 15, 2007, 02:59 PM

This is an excellent reference!! I'm a veteran of many surveys, but there was some new information in here even for me. Thank you!

Skeetersmom119 · Apr 11, 2008, 09:01 PM

Originally Posted by mercy1975

Here's some items that should be inserviced before your upcoming survey. These are alot of the areas the surveyors will be reviewing.

All staff to wear name tags

Greet and smile at surveyors as appropriate. They are guests in the facility and should be treated as guests. Offer water and coffee after breakfast is done.

Call residents by their names only

Nembulizers-include cleaning procedure

Inhalers-include cleaning procedure. Remind staff to shake the inhaler in-between puffs and offer water for resident to rinse mouth out.

Accucheck machine-clean after every use!!

Eye Drops-if giving multiple eye drops, know how long to go in-between giving them

Injections

Peri-care--try to have two staff go together. They can coach each other. Keep residents appropriately covered during intimate procedures.

Emptying of Foley bags

Tube medications-Do each med separately and flush between each med

Med pass- remind staff to use hand gel every time after giving a resident’s meds. Wash hands with soap and water after every 5th resident.

Policy and Procedure for Cleaning Razors

Positioning of residents

All residents to receive appropriate cueing and assistance during meals.

Keep all hazardous items locked up

All residents to be appropriate dressed

Man shaved by 10am

If wheeling a resident in a w/c their leg extensions must be on and feet appropriately placed.

All O2 tubing should be in a plastic bag and not laying on the floor.

Keep clean and dirty items separated by three feet minimum.

All staff to know where the care plans are located.

We just finished with our survey. They came in at 7pm Monday evening. It was our annual + 6 complaints which were all unsubstatiated. This was my second survey as a LPN, I went through 6 surveys as a dietary manager prior. I noticed that they were focusing a lot on environmental and ensuring that the patient's privacy was maintained. This is great info to keep fo reference.

**VivaLasViejas** · Apr 11, 2008, 09:30 PM

We had ours in January, and although my department came out deficiency-free, we did get dinged on training and orientation (or in our case, lack thereof). Lots of changes had to be made in our programs to get us in compliance...........so, the take-home lesson here is to make sure there is plenty of evidence that staff have had pre-service orientation, received adequate on-the-job training, and been checked off on skills BEFORE working alone with residents. Not easy to do in LTC, but that's the standard they're holding us to now.

*noc4senuf* · Apr 12, 2008, 06:45 AM

These lists would work for those in states that are being surveyed by the older format but, there is changes with the QIS.

We do not give TF meds individually but, combine them if applicable since the TF usually have a precise amount of free water they are administered in a 24 hour period.

CapeCodMermaid · Apr 15, 2008, 03:49 PM

Originally Posted by noc4senuf

These lists would work for those in states that are being surveyed by the older format but, there is changes with the QIS.

We do not give TF meds individually but, combine them if applicable since the TF usually have a precise amount of free water they are administered in a 24 hour period.

We would get cited for giving G tube meds all at once...stupid because they take them po all at once. The amount of water used for preflush,between med flush, and post flush should all be taken into account when calculating the amount of free water given.

*noc4senuf* · Apr 15, 2008, 03:56 PM

Our policy on TF was scrutinized last fall when the state was in.... it passed with flying colors. Even the water used to mix the meds is taken into account for the amount of free water given.

CapeCodMermaid · Apr 15, 2008, 04:40 PM

We all need to go by our own STATE guidelines.

Ginger45 · Apr 25, 2008, 09:03 AM

We have to follow the Federal Guidelines, those are universal. My preparation for survey besides the excellent list above. Provide excellent patient care.

Survey Preparation

Survey Preparation

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