Every year, your facility CMS certification survey is premised on a
selected sample approach. The entire first phase of the survey is simply to identify a
sample to review. The fact that there is such low tolerance for lack of compliance is based on the fact that when a representative sample is selected, it likely represents the care that is given in the facility. When issues of non-compliance are identified in the selected sample, the sample then may be expanded to determine the scope and severity of the findings.
The surveyors choose the sample in several ways. They may ask for a list of residents who are within a category that was problematic on previous surveys to see if the issue has been satisfactorily handled. They may also select residents who have been the subject of letters of complaint to CMS or the health department, and in order to maintain the confidentiality of that complainant and to see if a problem is widespread, they may ask for a list of similar residents. And, of course, they ask for residents who have triggered for sentinel events or who are representative of triggered quality indicators.
Additionally, they typically will ask to review residents with special needs-- such as those who are younger than usual in a nursing home and may have specific activity requirements, those with developmental disabilities or mental illness, or
those who primary language is not English.
In the process of your ongoing survey preparation, it is important to maintain lists
throughout the year of residents who may meet the above described criteria. Once these
residents are identified, their care and documentation should be reviewed so that you
can be assured that if they are selected as part of the sample, they will not present a
problem that you are not aware of.
When you retrospectively review a record, remember that you cannot go back and change, or ask to be changed, any documentation of what was done
for the resident. You can make sure that if there were problems with how care was delivered, that these issues have been addressed and care planned
for the prevent recurrence, and that the issue is referred to quality assurance and a plan of
correction is developed and implemented. This way, if the problem is identified on survey, it will be apparent to the surveyor that the issue was already
identified and acted upon. This may not prevent a deficiency, but it may lessen the scope and severity of the citation. One appropriate measure you can take is a review note. Label the note "DNS Review" or "Medical Director Review" and summarize
the care that was given and why if it may be helpful and outline the revised plan of care based on the events described. For example, in a resident with a low risk pressure ulcer developed, a medical director may write a note about why the ulcer occurred
despite the outlined preventive measures and why it may have been unavoidable, as well as what is being done about it.
Joseph Tomaino is a patient care executive, educator, and consultant. Through his exciting web site, he provides practical and innovative information and products that support the cost effective provision of quality patient care in acute, sub-acute, long term care, and home care settings. Visit www.continuingcareinsite.info to subscribe to free newsletter.
© Copyright, 2006 All rights reserved, Joseph J. Tomaino, The Tomaino Group, 834 Heritage Court, Yorktown Heights, NY 10598 Email: jtomaino@continuingcareinsite.info
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