24/7 Survey Ready
How to Prepare for a Survey and Be Ready Every Day: An interview with Shelly Maffia, Director of Regulatory Services
Q:
Why is it important for facilities to be survey-ready every day, not just during survey windows?
A:
Being survey-ready every day ensures that facilities maintain consistent compliance with regulatory standards, which ultimately improves resident care and outcomes. Survey readiness isn’t just about passing inspections—it’s about fostering a culture of excellence that staff and residents can rely on. In contrast, waiting until a survey is announced can leave facilities scrambling to fix avoidable issues, which increases stress and the risk of non-compliance.
Q:
What are some common pitfalls facilities encounter when trying to maintain survey readiness?
A:
- Incomplete or outdated documentation: Missing policies, outdated care plans, or incomplete training records are common red flags.
- Lack of consistent staff training: Without ongoing education, staff may not fully understand or implement compliance measures effectively.
- Reactive rather than proactive QAPI processes: Facilities often wait for problems to arise instead of continuously monitoring and improving practices.
- Environment of care lapses: Simple issues, such as cluttered hallways or malfunctioning equipment, can signal broader compliance concerns.
Q:
What tools have you found particularly helpful to address these challenges?
A:
The Survey Ready Toolkit is specifically designed to help facilities navigate these and other challenges. Proactive consultants pooled resources we have used to drive survey success into a single actionable program that is easy for facilities to roll out. Key tools include:
- Weekly Checklists:
These checklists help ensure critical areas are reviewed weekly for compliance, serving as an excellent resource for departmental audits. - Survey in Progress Checklists:
Department-specific checklists focus on key areas to monitor during routine rounds while a survey is in progress. They help identify and address gaps proactively. - Compliance Roud Audit:
This tool is ideal for routine department head rounds, allowing proactive assessment of daily compliance practices and quick identification and remedy of potential issues.
Q:
Can you share an example of how one of these tools made a difference?
A:
Of course! During a weekly audit, a facility used the Week #5 Checklist to systematically review infection control practices and care documentation.
- One critical finding was in the Infection Control book: while the monthly summary and line listings were complete, there was no action plan in place to address recurring urinary tract infections (UTIs). By identifying this gap, the Infection Preventionist collaborated with the facility team to develop an action plan, including staff education on catheter care and enhanced hydration protocols. Over the following months, the facility saw a measurable reduction in UTIs.
- The checklist also flagged incomplete TB testing records for new staff members. By reviewing policies and conducting immediate catch-up testing, the facility ensured compliance with its TB prevention plan, avoiding a potential citation.
- Finally, during a Kardex review, the team discovered that updates about fall prevention interventions for two residents had not been communicated to CNA staff. This oversight was resolved by implementing a standardized communication process for care plan changes during shift huddles.
Using the Weekly Checklists, the facility not only improved compliance with infection control and care documentation, but also enhanced communication and teamwork, ultimately leading to better resident outcomes.
Q:
What’s your top tip for maintaining survey readiness?
A:
Consistency is key. Establish routines with systems for regular audits, team check-ins, and ongoing staff education. Staff pay attention to what you pay attention to! Remember, survey readiness is a team effort—engage every staff member in understanding their role in compliance and quality care.
Q:
How can the Survey Series and Survey Ready Toolkit help facilities prepare for 2025 and beyond?
A:
The Survey Smart Webinar Series provides expert guidance on navigating regulatory updates, addressing common citations, and implementing best practices. Paired with the Survey Ready Toolkit, these resources empower facilities to confidently meet compliance standards and provide exceptional care.
Q:
How can someone get started with these resources?
A:
We’re launching the 2025 Survey Smart Series January 14, 2025 with a discussion of avoiding deficiencies related to F689-Free of Accident Hazards/Supervision/Devices! Join us to gain actionable insights and expert guidance for maintaining year-round survey preparedness. If you miss a session, don’t worry, series purchasers receive on-demand access to past sessions.
Access the Survey Ready toolkit for detailed action plans and resources for the interdisciplinary team to drive perpetual survey success.
Interview With:
Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CPC, CLNC
Director of Regulatory Services
Proactive LTC Consulting
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