Friday, May 30, 2008

Survey Paranoia

Some time ago I bought a bunch of nursing home books on ebay and came into possession of a mini-manual from one of the state nursing home associations (which will remain anonymous) on how to effectively manage surveys. Some of it was quite good, such as making sure that staff did not acknowledge guilt. This would be evidenced by a surveyor's statement on the 2567 (Statement of Deficiencies) that stated "The DON admitted that the CNA should have never done that", for instance. Some of it was bad, such as the suggested method for doing mock surveys that I will not go into here. And some of was disturbing. One particular chapter of this manual was devoted to keeping tabs on the surveyors. It actually stated that "an unobtrusive surveillance system to keep tabs on the essential". If that is not possible, the manual states, a staff member should be placed outside the door with walkie-talkie access to the administrator. Now before I go any further, I want to make it clear that this manual was about 15 years old, and would probably no longer be applicable because the state this came from currently utilizes a different type of survey protocol. But is goes to perfectly illustrate the industry's ridiculously paranoid attitude toward regulatory compliance. Interestingly enough, a expose that came out in 1997 ("Patients, Pain, and Politics") described similar behavior going back to the 1960's, when nursing home regulation was nothing compared to what it is today. Even when I worked the floor just a few years back this same attitude was the rigor de norm. Everyone sneaked around, talked in hushed tones, and tried to predict which resident would be interviewed next. As a consultant, I still see this behavior.

Nursing home surveys are nothing to be paranoid about, unless you're trying to hide your substantial noncompliance. Survey protocol is clearly spelled out in the State Operations Manual. It should be no mystery who gets interviewed, because the manual tells you. "But the surveyor's don't do things by the book!", I can hear someone cry. If they don't, then appeal it. That's what IDR and the appeals process is for. The reason that deficiencies happen is primarily because nobody knows the rules of the game called survey. As I cannot emphasize enough, TEACH YOUR STAFF THE STATE OPERATIONS MANUAL!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Of course this is a problem if you don't know it yourself. When a week long DON orientation attempts to cover everything about survey in 45 minutes, and the required text for virtually every AIT program in the country doesn't even mention the word 'survey', it's not entirely your fault. But if you haven't been taught it, you need to learn it for yourself. As anyone who has ever tried to read the watermelon book cover to cover can tell you (myself included), it's one hell of a boring book. Perhaps you could try this instead: Get the forms used in the quality indicator survey and do mock surveys through QAA committee with them. You will learn the rules as you go along because the contain the relevant F tags and the critical elements necessary for demonstrating compliance with them.

You can be paranoid about state if you want, but it's a waste of time and energy you probably don't have. If your facility is not survey ready when they walk in the door, there is only so much you can do to fix things while the surveyors aren't looking. Doing well on survey takes staff education and frequent mini mock surveys conducted over the course of the entire year. Waiting until you're already inside the window is uselsss.


Patti said...

LOL! Don't we know IT here? Survey madness is what some call it. The bosses get all panicky and sappy when the state is IN house. They run around wiping the sweat off their brows as they spray down corridors with smelly deodorizers, while if they just had a couple more CNA's there would be NO odors to cover up...

They tell the aides NOT to speak, not to offer any info, not do this, not do that...I think each survey team should have a CNA as a member!Only the aides can really see what is going on- and I don't CARE what anyone thinks of this. It is fact.

Surveys should be learning experiences and not viewed as some super secret megaevent.

Anonymous said...

That last statement is well enough said. . .if any of the process made sense, or at least had anything at all to do with the welfare of the residents.But anyone on the inside of health care today knows--this is NOT the case-the endless amount of paperwork leaves little time to actually care for your residents. And to take the survey so casual and think of it as a "learning" experience is an innocent enough thought--until your facility is faced with not being able to admit new residents, and possibly farm out the ones you do have--all the while knowing that your facility takes very good care of their residents--but due to all the red tape and politics involved, that is not even an issue come survey time. Take this scenario--a true account of one such point,as a surveyor stood by monitoring every move a C.N.A. team made while readying a resident for the day, with personal hygiene and then dressing. As is often the case, one of the caregivers was very new at her job, and the other so nervous he could barely function. After performing peri-care, (which in this case the resident had been incontinent of BM) the new employee, paralyzed by the scrutiny and questioning, suddenly forgot the appropriate precautions while performing such cares, and forgot to even remove the gloves she had just used to clean up the BM. She reached for the resident's toothbrush, picked it up, ran it under water, flipped the bristles with her still gloved hand, and applied the toothpaste. Now at this point, I'm thinking, surely the surveyor would stop the employee and recount what she had just done-and of course instruct her to dispose of the toothbrush along with the soiled gloves.NOT the case. As she stood by watching, the surveyor allowed the C.N.A. to commence to brushing the resident's teeth with the contaminated toothbrush. At this, I say--who is the perpetrator here? It was obvious that the employee needed further instruction and classroom practice, but at least her mistake was not intentional to harm the resident. On the other hand-the Surveyor knowingly allowed the resident to be exposed to (only God knows how many) pathogens while she stood by watching--all in the name of--what-resident advocate by monitoring and making sure the facility was in compliance with cares? I think NOT! At the point the toothbrush was loaded with the toothpaste-the next step should have been obvious-obvious enough to stop the employee at this point. The effect would have been the same, as the intention of the aide was clear. I will never be convinced that this was not a criminal act--and will probably never cease to find justice for the unknowing resident as her advocate--so get ready to face the music and come to your senses if you happen to be a surveyor with any similar dilemma--I'd hate to be the one that was made to read the tag summary out loud to the state board, spelling out exactly what I did to "protect" the residents from poor quality care.