Introduction

To receive Medicare or Medicaid reimbursement, nursing homes must undergo yearly inspections by state accrediting organizations which follow state and Federal standards and guidelines regarding quality care. Every nursing care facility that wishes to be reimbursed, funded, or benefit from government funds and financing must undergo a thorough survey process which may last anywhere from a few days to a week or more.

Understanding the survey process and the types of things that surveyors look for in nursing homes and assisted living facilities can help patients and their families choose the best care facilities for their loved ones. For the sake of simplicity regarding this article, we are using the term nursing home to define any type of elderly care facility.

What Surveyors Look For

Surveyors offering accreditation and certification to elderly care facilities initiate inspections on a yearly basis that look at a variety of different things within the nursing home or other care environment.

The inspection or survey team not only observes and researches nursing care processes, but also interactions between staff and residents, the nursing home environment, cleanliness, and the overall state of physical and mental wellness of its residents. For example, long-term care facilities and nursing homes must follow a variety of standards of care in:

• Resident rights.

• Admission, transfer, and discharge rights.

• Resident behavior and facility practices.

• Quality of life.

• Resident assessment.

• Nursing services.

• Dietary services.

• Physician Services.

• Specialized rehabilitative services.

• Dental services.

• Pharmacy services.

• Infection control.

• Physical environment.

• Administration.

Dental and vision based services are usually offered off site, with regular appointments and transportation offered by and facilitated by the staff at the nursing home. State and Federal guidelines and regulations determine the definitions, specifications, and scope of each of these requirements for accreditation and certification.

Survey results are to be made available to all nursing home residents, their families, and the community. In addition to the resident's rights, surveyors and inspectors ensure the rights of residents to free choice, such as choosing their own physicians and ensuring access to any information regarding advanced care. Patients also have a right to confidentiality, and a right to voice grievances. State surveyors focus very carefully on grievances voiced by residents or their families and typically investigate all grievances for resolution.

Surveyor Guidelines

Surveyors pay special attention to the safety and security of residents in nursing home environments. They'll look at accidents in bathing facilities, falls, room accidents, and what triggers falls in any given environment. They may check for handrails along hallways, in bathrooms, and on beds when necessary for patient safety. They'll assess the safety standards of the facility, including disaster plans, emergency evacuation plans, and access to emergency transportation and services.

Surveyors will also determine whether activities meet measurable objectives and meet the interest, abilities, and preferences of residents. Activities should also offer residents with continuation of life interests as well as the ability to connect within their community.

In the area of nutrition, state surveyors will look at facility menus, food preferences, food preparation, and serving methods depending on the capabilities and mental status of residents. They'll check the weight of residents to make sure that they are neither underweight nor overweight, and that dietary menus are well balanced and nutritious.
 

State surveyors will also carefully inspect medical records for errors in medications, treatment protocols, and care plans. Care plans must be evaluated and revised as the patient or resident's physical and mental status changes and offer measurable outcomes and objectives. Care plans are designed to maintain resident independence and the resident's needs, strengths, and preferences.

Surveyors will also look for red flags, such as:

• Bedsores or decubitus ulcers.

• Lack of bathing, grooming, and basic hygiene of residents.

• Inadequate pain management.

• Falls.

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In a nursing home, falls occur occasionally, but a nursing home that has an unusually high number of fall incidents may initiate a red flag. The presence of bedsores on patients is also a red flag for state surveyors. These red flags are called tags or deficiencies. The number of tags or deficiencies a nursing home facility receives is directly related to its efficiency, quality, and standard of care.

It is relatively rare that a nursing home does not receive a few tags during yearly state inspections. Anything from a catheter bag tube hanging too close to the floor, to a resident not having water in their room can result in a deficiency tag by state surveyors. For example, a sample page from The Long Term Care Survey guidelines offered by state nursing home inspectors for the State of Colorado may read something like this:

Investigative Protocol - Hydration

Objectives:

• To determine if the facility identified risk factors which lead to dehydration and developed an appropriate preventative care plan; and

• To determine if the facility provided the resident with sufficient fluid intake to maintain proper hydration and assistance.

Task 5: Use.

Use this protocol for the following situations:

• A sample of resident who flagged for the sentinel event of dehydration (QM/QI 7 0.3);

• A sampled resident who has one or more of the following QM/QI conditions:

* Prevalence of fecal impaction;

* Residents with urinary tract infections;

* Residents who lose too much weight;

* Prevalence of tube feeding;

* Residents whose need for help with daily activities has increased; and

* Any of the three pressure ulcer QM/QI: 12.1, 12.2, or 13.3.

• A sampled resident who was discovered to have any of the following risk factors: vomiting/diarrhea resulting in fluid loss, elevated temperatures, and/or infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease, disfavor, a history of refusing fluids, limited fluid intake, or lacking the sensation of thirst.

• As you can see, observations, procedures and determination of compliance to guidelines are very detailed and comprise hundreds of pages of rules, regulations and guidelines that must be followed by nursing home staff and facilities in order to be accredited.

Bedsores are a major red flag for nursing homes, as bedsores are commonly caused by patients having to remain in the same position for too long. State guidelines require that nursing home residents be transferred or resituated every 2 to 3 hours in order to prevent pressure sores, skin injuries or skin tears.

Cleanliness such as clean and brushed hair, clean and clipped fingernails, proper skin care, and clean clothes of residents are observed by survey staff, as is the overall wellbeing and comfort of residents. State surveyors will check medical records and nurse's notes to determine whether pain medication is adequate or if residents are being under- or over-medicated.

One of the most important aspects of surveys is in the area of risk management. Bruises, fractures, or injuries due to carelessness, lack of supervision, or improper care by nursing home facilities may result in serious infractions, fines, and deficiencies that may seriously hamper the ability of the facility to accept new patients. In severe or life threatening cases, a nursing home or facility may be shut down and residents transferred elsewhere.

Seniors or any family member considering placing a senior or elderly loved one in a nursing home should know how many deficiency tags a nursing home has and their severity. Site Improvement Program, the Department of Human Health and Services and the Centers for Medicare and Medicaid Services (CMS) determine enforcement of nursing home quality.

Deficiency tags are categorized as follows, the first letter designates isolated incidents, the second letter designates a pattern, and the third letter in each category designates widespread observance:

• A, B, or C = no actual harm, with potential for minimum harm.

• D, E, F = no actual harm, with potential for more than minimal harm that is not immediate jeopardy.

• G, H, I = actual harm that is not immediate jeopardy.

• J, K, L = immediate jeopardy to resident health or safety.

Consumers may be comforted to know that the average of nursing homes inspected in the United States today range in the A through F category. As of 2001, states which had the fewest deficiencies included Virginia, Vermont, New Hampshire, and Massachusetts. The states with the highest deficiency rates included California, Nevada, Washington D.C., and Arizona. However, residents in all states must realize that the inspection standards among certain states differ as to differences in quality of care, case mix, as well as surveyor practices.