New DON help with survey

Specialties LTC Directors


  • by meljam
    Specializes in ER / LTC.

Im a New DON at a LTC facility in Missouri and we are expecting our Survey soon. I am wondering if anyone can offer advice or a web-site that can give Tips in preparing for this. I enjoy my job tremendously and have not had the opportunity to work through a survey.

I am determined to do well and to prove that they have chosen the right person for this position.

I am looking for any forms or any help in knowing exactly what they are looking for, and also something to help me in completing my 802.


251 Posts

I would post your question in Nursing Specialties. There's a section just for DON / ADON'S. They might be better to help. Or get you a quicker response. These are my thoughts use them as you wish..

Specializes in Family Practice, Mental Health.

Does anyone in corporate office wish to provide you with a source of information specific to your state's laws?

- Oh....and do you have a copy of the prior survey results?


1 Article; 463 Posts

Specializes in MSP, Informatics.

each agency does a different type of survey, and each year they focus on different things. Do you know anyone in your area or region that has a similar facility with the same agency that may have already had this years survey? I know some years the Joint Com looks at very different things, but they seem to hit those things in every place they survey.

also doing mock surveys of your facility is a great way to prepare.


12 Posts

Specializes in ER / LTC.

I have last years survey, but I'm not sure how to do a Mock survey, any suggestions:crying2:


85 Posts

I'm in Ohio so not sure what is different. I have also had trouble with the 802 since we switched to 3.0 because our software doesn't automatically complete it for me anymore. I started out with a blank form and just went through and completed it once ( which did take a long time) After that I just kept it updated with each new admission and with stand up each morning with any new orders/falls etc...... We had survey last week and ended up with 2 minor cites.

Specializes in LTC, Hospice, Case Management.
I have last years survey, but I'm not sure how to do a Mock survey, any suggestions:crying2:

Try to do your 802 on paper & keep it up as another poster suggested.

Take your completed 802 and look across to see who pops out at you with the most "X's".

Plan to take your top 3-4 problem residents (those with all the X's) and tear their charts apart...look at the MDS, read the careplan line by line, read the nurses notes & MD orders (were family notified of changes/new orders). Check their lab orders and verify that the labs are getting done. Go look at the resident, are they clean/nails trimmed/happy with care. If they have a skin treatment, watch the nurse do it...can they do it while maintaining infection control with no cross contamination. Watch a med pass - get the staff used to being watch so they don't "freak out" as bad when a surveyor is watching. Go to resident counsil meeting, listen to their complaints (because chances are they are going to tell surveyors the same things)..HAVE A PLAN TO FIX THOSE COMPLAINTS.

The following week...pick 3-4 new charts and start over. In time you may begin to notice a pattern, like labs not being done timely. At that point you need to have an action plan in place to get this area corrected. Hopefully if you stay on top of your problem areas, survey won't be so scary.


12 Posts

Specializes in ER / LTC.

Thank you all very much for the information.

One more question, where can I find instructions on filling

Out the 802


2 Posts

I am in California but you may ask your MDS Coordinator to obtain blank 802 form for you to start and fill in weekly/monthly for those patients that will be triggered. Ask MDS nurse to print you an 802 which will generate listings of active and sometimes discharged residents. Review all columns and far right of form will indicate amount of items triggered. Pick 2-3 patients you want to do chart review from front to back to help qa the chart but you will be able to validate any issues (care plans/consents if applicable/fit notes to support changes in condition/justified nursing notes, etc)

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6,090 Posts

Specializes in Gerontology, Med surg, Home Health.

You can find the instructions for the 802 on line.

In Massachusetts, you can't just go to a resident council meeting. You MUST be invited.

Make sure you're following your policies....falls and followups. Infection control is huge around here. IV documentation is an easy one for them to target. I+Os need to be complete. Behaviors documented on people taking psychotropics. Clean med rooms. Check for expired meds. Name tags, handwashing, resident respect...knock on door before you go in the room. Cover up the MAR when you walk away from the cart.

Make them work hard for any tag they give you. Good luck. First one is the most nerve wracking.

you'll find the directions here.


15 Posts

As floor charge nurse for many years, somethings I knew helped to prepare during a survey was management nursing staff frequently check Med cart. Narcotic signatures and members of idt doing daily rounds with each resident asking if there and issues and addressing them make sure everyone is happy and us doing that our residents had no complaint ?

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