In the upcoming era of risk-based surveys, consistency in storing and accessing patient data across facilities, especially following mergers and acquisitions, is ever more important. Providers will have to reconcile with some things remaining the same, however, including surveyor subjectivity.
Even as the change to the risk-based survey process has been lauded by the sector for improving inspection lags and bears rewards for facilities with top ratings, providers are all too aware that survey results can still vary depending on the surveyor. To minimize subjectivity, Venza Care’s Chief Nursing Officer Lisa Chubb advises having patient data ready at your fingertips. The new process is laden with 11 stringent qualifications around star ratings and schizophrenia diagnoses, and facilities will need to do a lot of work to meet these conditions, Chubb said.
Chubb suggests operators have a survey readiness binder ready to go when surveyors enter the building. The binder shows up-to-date entrance requirements and electronic health record click path instructions, a helpful tool especially if mergers and acquisitions have happened recently.
“Every different organization that a surveyor goes to looks different,” Chubb said of EMRs. “Make sure that they understand where to go, what they can look at, and then ensure that you have it connected correctly so that they can see what they need to see. Nothing frustrates the surveyor more than if they can’t see what they need to see, and they feel like you’re hiding something. So then it’s like the gloves are off and the war is on.”
Moreover, Chubb noted that about 85% of all surveys are complaint surveys, and that the whole inspections process is still underfunded. On top of that, the federal survey budget has been virtually flat since 2015, all while inflation has gone through the roof. Meaning, CMS has had to work with a constrained survey budget and overworked surveyors, for which the facilities will need to compensate.
“A lot of times CMS uses the phrase, ‘bad actors.’ How do we ensure that we’re taking care of bad actors? You can’t put everybody in a bad actor bucket,” said Chubb. “We’re inching toward a great place, and I think CMS is more open now to what we need as an industry, and they’re listening. I commend them for that because we are going to have to work together to win.”
That said, facilities must prepare, especially those left out of receiving the quicker, streamlined surveys.
Chubb shared tips on how to prepare, and more broadly, what should be shared with surveyors at this month’s RETHINK Forum. Facility leaders should not overwhelm surveyors with a flood of data after all, she said, and they should also ensure they’re following attorney-client confidentiality and quality assurance legal protections.
Only 12% of facilities qualify for the risk-based survey, which means roughly 1,400 facilities will be locked out of the model because their states are behind on surveys. In certain states like Alabama, zero facilities will qualify, according to CMS data.
New Jersey-based Venza operates in seven states, including North Carolina, Tennessee, Kentucky, Alabama, Louisiana, Maryland and Delaware.
Practical prep for risk-based surveys
Nursing homes need to make sure their CMS-802 document is continuously updated as the agency goes forward with risk-based surveys as well. The document lists all current residents and maps out key clinical categories, diagnoses and treatments, noting high-risk medications, pressure ulcers and facility-acquired wounds, nutrition and weight, among other categories.
The risk-based survey isn’t going to be easier or lighter, because subjectivity is still going to play a huge role.
“You’re going to have one, two, maybe three surveyors, depending on the census size of your building, and they’re not going to be able to bounce things off of each other as much, and we all know that your biggest predictor of your survey outcome is your zip code. So there’s subjectivity across every single state across the country,” said Chubb.
While operators can’t exactly anticipate surveyor subjectivity, then can polish their CMS-802 form, pulling the high-risk patient list surveyors will need and scrub records and charts, looking at patients more closely and more thoroughly as survey times approach.
Infection control, Chubb said, is the only critical element pathway, the only mandatory task that risk-based surveyors will be completing. It is, after all, still the number one tag in the country, she said.
“Really brush up on that because it is going to be a huge focus. Before it was our kitchen, doing kitchen sanitation reviews. Still do those things always, but now the focus is going to be really heavily around infection control,” said Chubb.
Sharing with surveyors
It can be difficult to determine what to share with surveyors, Chubb said. Staff shouldn’t overwhelm surveyors with a flood of data but getting statements for a complaint survey should absolutely be a focus.
“Investigate thoroughly, make sure that you have very tight processes around your risk management, and that you’re compliant with those processes,” said Chubb. “It’s always a best practice to make sure that you, as a leader, are taking the statement and you’re typing it, and then the person giving it is signing it and agreeing that what you typed is factual, of course.”
But sometimes, emotions run high when witnesses need to share what happened for an incident report. As a clinical leader, keeping a cool head and getting statements down and checked is the best thing you can do.
There are some items that are quality assurance (QA) protected, she said, referring to legal protections that keeps internal audits and medical peer review records confidential and shielded from discovery in lawsuits. And, other documents could be protected by attorney-client privilege, Chubb said.
The key here is recognizing when it’s something that intersects with the care provided, or an incident that happened with the patient at the time, then the patient’s record should be handed over to the surveyor along with anything that entails, she said.
“When we’re sending reportable incidents over and notifying the state or CMS of certain things, there have been times as chief nursing officer that I’ve gotten on the phone with a deputy director and said, ‘you’re going to see this come across, but I want to verbally share with you what’s going on,’” said Chubb.
Open communication in these cases can diffuse a bump in the relationship before it starts, because the minute surveyors think an operator isn’t being transparent, honest or forthcoming with information, is when they start digging in, she added.
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