Survey Readiness

This video is intended to give you a general overview

of the state survey process and the copy program here

at mountain view manner.

I will discuss the purpose of surveys and how to

prepare for your part of the process.

I will give you some important tips to help with

surveyor questions and requests.

Then I will discuss the quality assurance performance improvement program,

including the what and how of Coffee CMS.

State surveys govern the delivery of care and services within

the organization.

These guidelines are in place to ensure that all residents

receive the highest quality of care.

There are two types of inspections or surveys.

The first is an annual survey that happens every year

and takes about 3-4 days unless surveyors have concerns in

which it may be longer surveys can happen any time

during the year, at any time of the day in

any day of the week.

They are always unannounced.

The second type of survey is a complaint survey and

that's a survey that arises following a specific complaint against

the facility and it looks specifically at areas that are

related to that complaint.

It will not be made known who filed the complaint

and you will also not know when it will occur.

These types of surveys typically last 1-2 days and they

are complete when enough evidence is gathered to determine if

the complaint is valid regardless of the survey type.

Upon completing the survey, the surveyors were will decide if

any areas do not meet minimum health and safety standards

in unacceptable conditions.

The surveyors will issue a violation.

Also known as a citation tag deficiency or a finding

For each violation.

Your organization received.

The administrator along with nursing staff must develop and then

submit a plan of correction within 10 days after review

of the pOC or plan of correction, a post survey

revisit maybe completed to verify the organization corrected the violations.

It also may not be revisited if the plan of

correction meets the surveyors requirements and then depending on the

survey history and the type of violations that were cited.

Yeah. Some common tags or deficiencies um that relate to

the survey visits include residents rights, infection control, mealtimes and

dining the environment and plan of care.

So we're just going to talk a little bit specifically

about some of these tags and how we can avoid

them. The first one.

Residents rights referring to the right to dignity, privacy and

respect ways to avoid this violation.

In regards to breaching residents dignity privacy um include always

knocking and giving residents a chance to respond prior to

entering their private room when addressing residents, always be respectful

called them by the name that they wish to be

called. And again, always avoid pet names, provide privacy and

avoid exposing body parts unnecessarily when you're doing your cares

always dress residents in their own clothes and no nighttime

clothing in the day unless this is their preference, in

which case it should be care planned.

Urinary catheter bag should be covered at all times.

We never changed the tv or radio to our preference

but rather leave it at the preference of the residents.

The second common tag that is often given, relates to

infection control this year, a very common violation or tag

is given in relation to hand washing.

So that's why we've been so often going over our

hand washing policies and practices and again encouraging to do

you to rub in and rub out and knowing those

five points of contact when you need to be washing

your hands.

Um Please please don't miss an opportunity to wash your

hands. Uh huh.

Especially during the survey process if you're not sure, just

wash your hands.

A second infection prevention tag that's commonly coming as in

regards to PPE.

Or personal protective equipment.

So make sure you're always dressed in your correct PPE

for the care situations that you're in.

And importantly, please dispose of your PPE in the appropriate

receptacles. Never walk in halls while wearing PPE, never place

soiled linens on the floor or on clean surfaces.

They should be placed in bags for transport outside of

the residents rooms.

In regards to mealtimes and dining citations.

These can be avoided by making sure that your hands

are washed as well as a residence part eating, making

sure that the food corresponds to the specific diet of

the resident.

Always ensuring that residents receive appropriate level of support and

have their assistive devices that they have been care plan

for. And when you are assisting with eating, sit next

to the resident, don't ever stand over them or reach

across tables to them.

If a resident is refusing what they've been offered to

eat, you can please offer food substitutes and then also

determined do they need assistance?

Um, so don't just take the first refusal look for

ways to encourage leading talk to residents and meals even

if they cannot respond, please do not carry on conversations

with other employees.

This will result in a citation and finally, um, toilet

residents and provide personal hygiene.

Again, the hand washing before you take them to the

dining room for mealtimes and again, personal hygiene Afterward.

Finally, you know, use respectful terms.

Do not use terms like feeders or bibs.

Don't ever serve the meal on the food tray and

temperature is important.

And in the past, received citations for this.

So reheat as needed if the resident is eating too

slowly. Tax related to the environment, to deficiencies in the

safety cleanliness and home like nature of the environment.

Be certain to pick up after yourself when giving care,

check the residents room to ensure it is neat before

leaving. Make sure items are within reach, like the call

light and the water picture in their remote control.

Check for and always remove safety hazards.

Keep the noise level within the environment to a minimum.

Don't ever yell in the hallways to a coworker or

resident and finally a common deficiency.

Nursing homes received from surveyors related to plan of care,

surveyors will typically ask about planet cares.

They may ask you, how does the nurse communicate the

residents, changes such as illness or weight loss and how

they are addressed and documented.

So you should remember that at mountain view manner.

We communicate care plan updates during reports, Also during huddles

and in our sienna communication binder that you guys use.

And we will be implementing the use of the facility

bulletin board in the Pcc dashboard.

Um so when you log on to pcc you'll see

on your dashboard there's that home tab before you go

to pcc.

When there are updates in this, this home tab turns

red when there are new updates.

And until you look at it then after you look

at it will turn back to white.

So we want to begin using this communication tool at

the start of each shift.

And we want to all know that this is where

we communicate the care plan changes.

So how should you conduct yourself during the survey?

First of all to stay calm, you guys do a

great job and be confident in the job that you

do maintain your positive carrying attitude.

Smile, Be friendly to the surveyors.

Be cooperative when you are approached and asked questions of

them. Do not ever guess if you don't know the

answer or can't remember.

That's fine.

Just always know that you know can express to them

that you know where to find the answer.

So it's okay to say, I'm not sure.

But let me get the person who can best answer

your question or since you have me on the spot,

I just can't remember but I know where to find

the answer.

Let me find the answer for you.

Um Mind you surveyors are going to expect you to

be able to answer certain questions such as those surrounding

fire safety and abuse.

So these questions need to be ingrained in your mind.

You need to be able to to answer these questions

When you ask questions stick to you know the question

at hand less is more.

Don't just start rambling on about all kinds of other

things. And then finally if you are asked by a

survey to perform a demonstration you can you will but

please notify your D.

O. N.

Prior to that.

So some common questions include um that you may be

asked by surveyors.

To who do you report suspected cases of your views

and you need to know that you immediately report those

to your supervisor which maybe your charge nurse or deal

in or your administrator.

You need to know the types of abuse and the

signs and symptoms of abuse.

We've talked a lot about this.

You do an annual course for this.

If you have questions, please see me regarding this, you

need to know what happens when someone accuses an employee

of abuse and that is that the employees suspended pending

an investigation.

And um you also need to have committed to memory.

What is the first thing that you should do in

case of a fire is protect your residents.

And then the race acronym remove alarm contained, evacuate.

And also you need to know how to use the

fire extinguisher with the past paul ames squeeze sweep acronym.

Okay, so now we're going to quickly just talk about

the coffee program.

So while you already may have an understanding of what

this program is about, I'd like to just take a

couple minutes to discuss the how and why of coffee.

So again, copies Q.

A. P.

I. Stands for Quality Assessment Performance Improvement.

The federal government requires that every location that participates in

Medicare and Medicaid programs implement a quality program.

The goal of the Q.

A portion of copy, which stands for quality assurance or

quality assessment, is to prevent poor quality care and services

from reaching the people that we serve.

The P.

I. In copy references.

Performance improvement, which aims to solve the problems that are

identified by the quality assessment.

The coffee program is directed by a team of coffee

committee members that include our administrator dan, the director of

nursing, Janet, Medical director, DR Diana Carr V.

And Becky Gray, our new social worker who is our

designated coffee Coordinator.

These team members meet monthly where they reviewed data and

audits and developed tracking tools to determine areas of improvement

that are needed within the center.

Through their review, they determine significant areas of concern and

then develop performance improvement plans, also known as pIPs, to

solve these problems and improve care.

Any Mountain View Manor staff who has input or a

special interest in finding solutions to a particular problem identified

by the committee can and should be part of the

performance improvement team.

The principles of the Coffee Program aimed to encourage employees

to identify opportunities for improvement and share ideas for change.

The focus is on improving systems and processes rather than

blaming individuals when things go wrong.

The copy plans guide our work and help us to

clearly define goals, review those goals and update them as

needed. So please remember that copy is everyone's responsibility.

Everyone is expected to know what coffee projects are going

on and know that each of us has a voice

in improving our center and providing the best care possible

to the residents that we care for.

Survey Readiness

Chapters

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