Survey Tips and Friendly Reminders

Since the new requirements of participation went into effect November 28, 2016, here are some reminders of several issues you should be prepared for in regards to your next survey.

  1. Make sure that all staff, residents, and families have been made aware of any policy changes that you have made. This is especially important regarding new terminology that was included in the regulations, as well as reporting of abuse.
  2. When recording in-service hours for employees, please make sure that you indicate the time that the in-service began and ended. So instead of reporting one (1) hour for a CNA for an in-service, record 8:00 am – 9:00 am (1 hour). Times need to be indicated on in-service records.
  3. Exploitation needs to be spelled out in your abuse policies. Review the regulations regarding abuse, neglect, misappropriation of resident property, and exploitation as defined in F223 – F226 to ensure that you have your policies up to date.
  4. Remember to in-service staff regarding the reporting requirements of abuse. Staff will be interviewed as per usual as part of the survey process and they should be able to explain the reporting of abuse requirements. Staff need to be able to differentiate between different types of abuses, so knowing definitions and examples is important.

Example: Staff may be interviewed by the surveyor and asked to identify what type abuse situation is being described; “one of your coworkers’ locks a resident in a closet, what type of abuse is this?”

  1. Remember to update your Resident Rights Poster with the appropriate phone numbers, addresses, and email addresses.
  2. Policies should be updated and the term “resident representative” should be included as appropriate.
  3. Make sure that dementia management is included as needed in your policies. This is an important piece of abuse prevention and should be included at a minimum in your abuse policies as referenced in F226.
  4. Facilities need to be able to describe how residents receive and obtain internet access.
  5. Remember to have a routine maintenance schedule for side rails and mattresses and that you conduct assessments as needed. Check to make sure that mattresses are approved for the beds that are used by residents. Side rails and mattresses are mentioned several times in the new regulations and warrant attention.
  6. Remember to post three years of surveys in your facilities. You may also want to consider posting signs in various locations in the facility so that individuals know where the survey results are located.
  7. Make sure staff know what to do in case of a disaster. For example, flood, tornado, fire, etc. Staff may be interviewed and asked how to handle a disaster.
  8. Remember that any unusual or issues of concern might need to be placed through your quality assurance process. QAPI is a big focus this coming year with phase 2 so it is never too early to make sure that you are addressing issues and determining their root cause so that they might be prevented in the future.

Courtesy of Katrina Magdon Director Professional Development & Regulatory Affairs
Alabama Nursing Home Association