New ADON/ Survey Imminent!

  1. I am an ADON at a 120 bed skilled facility in Virginia. I have been through surveys before; once as a Medical Records Tech 10 years ago and in the past as a LPN on the floor. The surveys were easy; we did well. This is the first year as the ADON... I'm terrified! Ive been on vacation the past few times our facility was in Survey; What are they going to ask me? How do I respond? What if I don't have the answer? I've been told they will attack me because I'm a new ADON... Any help? BTW, the person before me did not organize well, so there are a lot of things missing in personnel files that I've been working on. PLEASE HELP, give me **ANY** hints and helps you can! Thanks! NurseGuyBri
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    About NurseGuyBri, BSN

    Joined: Jul '08; Posts: 314; Likes: 334
    Quality Assurance Consultant; from US
    Specialty: 6 year(s) of experience in LTC, Education, Management, QAPI


  3. by   CapeCodMermaid
    Take a breath. They will not attack you because you are new. Break what every you have to fix into manageable tasks. If you know what the problems are, make a start to fix them. Go through the new hires...they usually ask for the last 8 people (at least in my state). Make sure those records are good...especially if there is a new DON or Administrator.
    You can only do what you can do. If you don't know the answer, tell the surveyor you don't know but you'd be glad to find out. Be upfront with them so they don't go digging further than they have to. I'm always honest with the surveyors. Last year our medical records were awful. I hired a new medical records person. I had been there 2 months when DPH showed up and the medical records person had been there 3 days. I was honest and told them the last person had been a slug but the new person was great. They were very understanding when it took us 4 hours to find an old chart. You'll be fine.
    Let us know how it all works out.
  4. by   NurseGuyBri
    Thanks! I probably know what to do, but its always good to know someone else has been through it and can help! I'm nervous, but I do believe in our facility and our staff, as far as quality of life we are golden...
  5. by   Chin up
    Care plans, care plans, care plans. Make sure you have updated care plans. Appointments, if any were missed, make sure it is documented. Your MDS must match all documentation. Falls and incidents, care plan well. Right now in your window, look at documentation, nursing assessments, and care plans. Also make sure meds are properly written, including glucometer testing, cleaning and test documented. Sliding scales are like a magnet to them, make sure you have proper parameters. Just a few things, but ones they flock to in my facility, every year. Peace!
  6. by   debRN0417
    Don't freak out, it will be okay. You can only do what you can. Take your time. They will look for the following things in personnel files:
    What does your facility policy and procedure on abuse say that you are going to do to screen new employees for hire? Whatever your policy says, is what they will look for.
    Criminal record check done and back on the file within 30 days.
    Sworn statement prior to the criminal record check being sent.
    License verification and CNA certification: They will want the printed verification from the website for license look-up. If your policy says that you are going to do this prior to offering the job, or hire, then it must be dated (computer date) prior to hire or the offer.
    Two reference checks or two valid "efforts" that you have tried to get a reference. If the person has never worked anywhere before, then personal references will do.
    If it is just a standard survey then they will request a list of employee files hired within the last four months. If it is licensure then it will be for the past 2 years. If someones license has expired during that time, they will want to see that the license was verified upon hire and also that you verified the license again when it was renewed.
    If it is licensure, then they will want to see in the employee file evidence of training on the mandated/required inservices (abuse, resident rights, ect) that need to be done on orientation and annualy.
    Job descriptions in each file, signed and dated.
    Disciplinary actions.
    Go through the files and see what you are missing and get it done. You can then get the information, though it may be late, it will still be there, and formulate a plan of correction so that it does not occurr again. You still may be cited, but if you have a plan of correction in place (addressing all 5 points) then it could be considered past non-compliance, because you identified the situation and put a plan of correction in place. Make sure your allegation of correction date is prior to the surveyors coming and make sure that any files from that date forward have NO problems or that will invalidate your plan of correction.
    You should not be attacked by anyone. Just answer honsetly, and if you don't know, just say so and go find out.
  7. by   NurseGuyBri
    I just ran across this post- Almost funny. I am the OP and now, as the DON, I'm preparing for my first survey as the DON. I'm quite confident, but it still gets me anxious because no matter how good you are, we all make mistakes and I can't answer for all of them. I just hope the fact that we take great care of our patients and truly care shows. I *LOVE* this community online. Thank you all for the uplifting comments and the bridge to confidence when its a little shaky- and you dont even know me .