State surveys are coming.
The question for SNFs is simple: Will your facility be ready?
The key to navigating the state survey process is knowing what areas are most commonly explored. Here is a look at the top three areas most cited amongst surveyors, with insight from experts at Real Time Medical Systems, who discuss the steps SNFs can take for complete survey preparedness.
The key areas SNFs can focus on to improve quality of care
The road to a successful survey process starts not just with the care you deliver, but the care you document. That begins with the Minimum Data Set (MDS), the starting point for the survey. Surveyors obtain vital information regarding the patients in a facility prior to them even coming through the door and can see all the data that has been submitted on the MDS.
The accuracy of each item set is critical, and it is not just about the items that impact billing. The MDS provides information regarding each patient’s needs and capabilities, which then connect to the patient’s care and comprehensive plan.
“It is important for SNFs to utilize their own live data to know exactly what the survey teams will be looking at,” says Real Time Clinical Account Specialist Michele Self (MA, CCC SLP, CMA).
It is also important for SNFs to take concrete steps to improve quality of care. The three main steps are:
* Avoid preventable accidents and rehospitalizations through recognition of early subtle changes in patient behavior or condition and intervene in care with clinical actions that are aligned with a patient’s Advance Care Plan (ACP) and corresponding treatment.
* Reinforce safeguards against redundant medications by identifying potential side effects, interactions, and psychotic condition treatment. This allows SNFs to safely administer medications while minimizing the possible negative impacts to the patient.
* Achieve provision of quality of care by implementing the highest possible clinical standards, and through industry approved suggested interventions based on disease or condition. The inclusive psychosocial plan of care involves the patient, the family, and the staff to provide the best mental and physical care possible.
The 3 Most Cited Key Areas Amongst State Surveyors
Having a comprehensive care plan – Tag F655
The state survey process can be intimidating. But its foundation is really quite simple: a measurement of the care that you are already providing. That starts with building a comprehensive care plan for each patient.
“The correlation between the patient assessment and their care needs is powerful,” Self says. “It is easy to pull the MDS and care plan, put them side by side and determine if they support each other and represent the patient’s needs. With collaboration amongst the entire team on a patient’s care plan, allows for the best coordinated provision of care and improved outcomes. Also, when looking at other top tags, each has a connection to care planning, like quality care and infection control to name a few.”
As work with a patient progresses, SNFs must update care plans to reflect the adjustments made. However, providers can’t stop at the first step of the incident report completion.
“They must follow all points with a final check evaluating if the new intervention is working, and that the patient has no further incidents,” says Real Time Clinical Program Director Kathy Derleth (RN, BSN).
Ensuring quality of care – Tag F684
The care plan is the map, and the quality of care is the journey. State surveyors evaluate all areas that show quality of care, focusing on key areas that can be seen as harming a patient. These include accidents, such as falls, medication errors, elopements, or adverse drug events. They also include patient care areas such as pressure ulcers or weight loss. That means care providers must therefore be cautious in implementing deep clinical evaluations each day.
“One of the main challenges for care providers is the inability to have one-on-one, 24/7 contact with each patient,” Derleth says. “This can lead to patient accidents, such as falls, wandering without safety awareness or poor wound healing, all of which are more common than one would think. The staff needs to be vigilant every day with incident investigation, as well as patient specific interventions based on the root cause of the accident.”
Managing infection prevention and control – Tag F880
Even with the Public Health Emergency (PHE) officially over and facilities moving beyond COVID-19, infection prevention and control (IPC) remains among the top cited deficiencies. This should not be surprising. Now more than ever, SNFs have the task of maintaining strong IPC programs.
“With IPC being two of the top three cited areas for SNFs, the heightened oversight and enforcement of regulations will likely remain in place for the foreseeable future,” says Real Time Clinical Account Specialist Cheryl Scalzo (RN).
Breeches in IPC efforts can and have resulted in development of Healthcare Associated Infections (HAIs), increased Methicillin-resistant Staphylococcus aureus (MRSA), development of new multi-drug resistant organism (MDROs), and central line-associated bloodstream infections (CLABSI).
Additionally, care providers are now realizing the accountability of the Phase 3 Requirements that were initiated before the PHE and have since been revised. This guidance includes antibiotic stewardship programs, and the defined role of an Infection Preventionist.
That means that as facilities strive to improve their IPC efforts, their attention should focus in one area: prevention.
“The term ‘prevention; or forms of the word, such as preventionist, preventative, etc., is not only in the title of IPC programs, but is intentionally used with care providers guidance,” Scalzo says.
“Through a myriad of requirements and structured methods, successful IPC efforts work to prevent the spread of infections, the development of HAI’s and MDRO’s, adverse effects related to unnecessary antimicrobial therapy, and many more problems.”
This article is sponsored by Real Time Medical Systems, the industry-leading, KLAS-rated interventional analytics solution that turns data into actionable insights. To learn more about how you can get your SNF survey-ready with Real Time’s Interventional Analytics solution, contact us today.
