Not Fake News

The new nursing home survey process was rolled out on Nov. 28, 2017, and while there have not been a large number of surveys completed, LeadingAge NY members have begun to share their experiences to date. To no surprise, the surveys are taking longer to complete as surveyors become familiar with the new process and the associated software. At a recent meeting, the Department of Health (DOH) acknowledged that it will take time for the survey staff to become fully familiar with the new process. So far, according to DOH, about half of the homes surveyed had more deficiencies than in the prior survey, and the other half had less. With such a small sample size to date, it is hard to determine specific trends.

Areas that appear to be getting significant attention include Emergency Preparedness, where the interview with the Administrator is taking close to three hours to complete. In terms of the Facility Assessment (the review of which had been raised as a concern by members, since the amount and type of information contained in it could be utilized by surveyors to potentially identify deficiencies), it appears so far that survey staff are just determining that the document exists. In one survey, surveyors did review the Facility Assessment to determine if the area had been addressed. Some questions on Emergency Preparedness have been directed to both residents and their families to determine how they would be notified in an emergency.

Another area that appears to be a focus of the survey team relates to Infection Control. Staff knowledge of how to care for residents under precautions was looked at in several surveys. There were a number of observations as to whether staff was aware of infection control policies and whether they were followed. An additional focus was on policies/procedures related to Legionella.

At least two facilities were cited because, although the staff knocked, they did not wait for a resident to acknowledge them before they entered the room. The Resident Council interview is taking a long time, as the surveyor has many questions to explore. The Resident Council Interview worksheet has 24 individual questions requiring a yes or no response. In one facility, a citation was issued because some residents could not state where the survey results were located and also whether they had been told of their rights under the new nursing home regulations. The facility did take steps to inform residents but was cited anyway at B level.

The survey team seems to be looking closely at Care Plans and whether they are person-centered. Some additional areas included Accidents, specifically the issue of a resident getting the proper food consistency; the Storage of Drugs and Biologicals (outdated/expired medications); and the Drug Regimen Review that lacked a policy to address drug irregularities.

As stated before, the sample size is small, so at this time it is not possible to discern particular trends or patterns. As we gather more data, we will share findings with members.

Contact: Elliott Frost, efrost@leadingageny.org, 518-867-8832