Many long-term care providers strive to be ‘survey-ready’ all year round. But just like many of us schedule the big spring cleaning some time in advance of company arriving for their annual summer visit; some LTC providers opt to conduct a Mock Survey in anticipation of their annual licensure/certification visit.
Mock Surveys can serve several purposes:
- A Mock Survey can be an opportunity to take a fresh look at systems, procedures and processes of care, and identify potential survey-risk areas. And survey-risk can translate into litigation-risk.
- A Mock Survey also can reveal how staff will function under stressful circumstances.
Taking that fresh and objective look is essential in order to reap the maximum benefit from the Mock Survey process. LTC providers are discovering the hard way that the procedures, protocols and monitoring/QA systems that served them well enough in the past are no longer sufficient to avoid survey deficiencies. ‘But we’ve always done it this way; the surveyors never cited us on this in the past; we thought we were doing this correctly; we’ve always done well on our surveys before – how could this be happening?’ It is hard to stay current with new standards and the more stringent application of existing standards like F314 Pressure Ulcers, F315 Continence/Catheters, F323 Accidents, etc. It is hard to look at one’s own organization and see its shortcomings.
One way to get a fresh and objective perspective and to minimize survey-risk is to have the Mock Survey process conducted by someone external to your organization. This ‘someone’ could be a consultant or an experienced and well informed professional from a neighboring LTC community. If, however, you elect to manage the process using your own personnel, incorporating the following approaches can facilitate objectivity:
- Assign department heads to ‘survey’ departments other than their own. In nursing, have charge nurses/unit managers, supervisors, etc., assigned to audit other units and/or aspects of care for which they are not usually responsible. It is often hard to see your own forest for the trees.
- Although obviously the internal ‘surveyors’ will know that a Mock Survey will be taking place at some point, it could be more beneficial if direct care staff and other workers were not informed. This maximizes the surprise and stress factor.
- Even though the internal ‘surveyors’ know that the process is planned, the Mock Survey should be unannounced. The Administrator walks in one morning and proclaims it to be Mock Survey Day. This simulates ‘real life’ conditions...
The most important part of the Mock Survey process is what you do after it’s over. If you have about three months between the Mock Survey and the earliest likely date of the next survey, then I recommend the ‘Systems’ approach. The Systems approach includes a broader review and analysis of organizational policies, procedures, protocols and practices that may be contributing to Quality Indicator Report flags and/or to the ‘findings’ of the Mock Survey ‘survey team.’ If you have one month or less between the Mock Survey and the earliest likely date of the next survey, then I recommend you go into ‘Manage the Damage Mode.’ What are your high-risk areas, which residents have experienced negative outcomes, how can the risk be lessened and/or the negative outcome be explained and/or otherwise addressed?
In either scenario, “Systems” or “Manage the Damage Mode” develop a Corrective Action Roadmap that assigns responsibility, targets timeframes and breaks down the plan into operational steps.
Pre-survey preparation and risk management are the two most effective tools we have to weather today’s regulatory climate. Most LTC providers, if they haven’t endured it already themselves, know of a provider in their area- good reputation, well respected in their community, satisfactory survey history – that has been blown out of the water during their last survey. Wouldn’t you rather have a ‘friendly outsider’ or your own team discovers the dust-bunnies before the surveyors do?
Can you afford not to?
LeadingAge Kansas tools to help you with this issue
1. LeadingAge Kansas Survey Toolkit ß link to this on the website
2. LeadingAge Kansas Director of Nursing Toolkit ß link to this on the website
3. LeadingAge Kansas Risk Management Toolkit ß link to this on the website
Did you know?
LeadingAge Kansas will customize a post-survey toolkit just for your organization! If you receive any deficiencies on a survey, let us know within 48 hours of exit and provide a list of deficiencies and we will customize a toolkit of current LeadingAge Kansas resources to help you with your plan of correction. E-mail your request to Joe Ewert
or Debra Zehr