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Not sure about you, but I have always wanted the opportunity to sit down with a surveyor, totally candid and off the record, to gain the behind-the-scenes look and their perspective on the industry. This week, we had the opportunity to do just that.  

Surveyor perspective

This week I sit down with an experienced SNF surveyor from the State of Maryland. Lisa, we'll call her to keep her identity confidential, opened up about what it's like sitting on the other side of the table. Once you read through the interview, please email us any questions you would like to ask Lisa during our following discussion. We'll invite her back next month and have your questions answered.

Tell us about your background, how long you worked as a surveyor, and how have you used that experience to be a better clinical leader and operator now that you have shifted your career? 

I have been a nurse for 30 years. I started my career as a nurse aide at a State Psychiatric facility in Maryland. From there, I worked my way through LPN and RN school and continued my career as a Director of Nursing of a Gero-Psych Unit. After 17 years at the hospital, I transferred to the Office of Health Care Quality (the State Survey Agency in Maryland), where I worked for 13 years. In my role at OHCQ, I participated in annual complaint surveys, abuse investigations, Quality Assurance Survey's and the educator training new surveyors. I retired from State service after 30 years.

When I retired, I became a Regional Nurse Consultant for a SNF company in Maryland. The skills I learned in my career as a floor nurse and my time at OHCQ enabled me to look at both sides of the coin. Working in a skilled nursing facility can be very fulfilling, but it is challenging work. I have tried to be regional support that NHA and DON's can feel comfortable discussing any issue with me and coming to a resolution that best serves the residents and staff.

What are some of the things you've seen Administrators or operators do that piss off surveyors? 

Delay in obtaining entrance documents. The delay tells me that the facility is unprepared for when the State walks into the facility and doesn't take the process seriously.

The second item is the delay when the surveyor requests items from a resident's medical record, employee file, etc. It is prudent for every NHA to review any documents requested by a surveyor before handing them over, but taking more than 1/2hour or longer (I have seen requests turn into hours or days) provides the surveyor with the impression that the facility is trying to hide something.

On the flip side, what's the best way for a NHA to set the tone for a positive survey experience? 

Take the high road. Don't argue with a surveyor. Hear them out when a survey issue arises. If it is what it is, so be it. However, if there are documents or mitigating circumstances that you can provide while the survey is ongoing, DO IT and present your case.

If the surveyor presents a concern that you need to investigate further to ensure you can mitigate, the IDR process is for. I highly suggest that if you have a chance to remove a deficiency from the 2567, schedule the IDR. Surveyors are not always right (even though they think they are).

What are signs a surveyor has found an issue or is digging into an issue that should raise a red flag for an NHA? 

Always have your staff ready for the survey. With that said, managing the survey process is critical. Ensure your team knows to immediately contact you or your DON whenever a surveyor speaks to them and be aware when the surveyor asks multiple staff the same question. For example, a surveyor may ask several staff where they find a resident's code status in an emergency. One staff member might say the resident's code status is in the book at the nursing station. Another staff member might say their code status is in the physicians' orders section of the chart. Too many inconsistent answers from multiple staff could potentially lead to an IJ situation.

With COVID still very much at the forefront, what survey trends are you seeing or hearing? 

F tag-880 is causing a stir with the directed plans of correction and fines. I have seen a surveyor cite 1 example of a mask not worn properly in a non-resident area. This can cost the facility thousands of dollars in civil money penalties. I know that staff are exhausted, but infection control citations are on the rise and will continue for a very long time to come.

States were behind on annual surveys and complaints before the start of the pandemic. I am seeing that the survey process is going back to the facility's last annual survey. In Maryland, in some cases, surveyors are going back as far as 2018 (which is allowed based on the State Operational Manual). This means that the survey can take up to two weeks to complete, putting undue pressure on the staff. I would suggest reviewing any outstanding areas of concern conduct some audits, and if necessary, conducting an Ad-hoc QAPI in hopes of not getting an F-tag citation or, at best, a citation of past non-compliance.

Takeaways

So there we have it. 

Respond to requests timely. 

Present your case and supporting documents, but don't argue.  

Prepare your staff so they know how to respond to surveyor questions.  Consistency is key.  Make sure they report the questions and answers back to you.

Stay on top of infection control and prevention.

Maximize your Commute

I have found myself sliding into a slump lately and aimed to find a book that could set me in the right direction again.  This one did the trick. 

The Stoic Challenge by William B. Irvine gives you thought provoking tactics to change your mindset on facing challenges and setbacks.  My favorite quote from the book is "You simply remind yourself, at the present moment, almost regardless of what you're doing, you are quite likely living in the dream world of your future self."  Let that sink in.  Most likely, what I'm dreading doing today, any one of our residents would be thrilled to have the opportunity to experience again.

Grab your coffee and make it a great day.  We appreciate you and your dedication to your team and residents. -Thank you!