Nursing Home Social Services Reference/State Surveys/Survey Readiness

Nursing Homes are able to keep track of the interval within which the survey of their facility will take place. By regulation, annual surveys take place every 9-15 months, State CMS survery teams like to maintain an average of every 12 months. Outside of this interval, complaint investigations may be triggered when formal complaints are made by residents, families, or staff about quality of care or incidents of alleged abuse. The actual timing of a survey depends on the local CMS survey team. Having a timeframe for the annual survey of a particular Nursing Home allows the Social Services department and other departments to prepare. Social Services typically manages the complaint forms or concern forms that residents will file about their issues. This and verbal channels are how resident and family issues are resolved. Many facilities accept verbal complaints and fill out a complaint form as a way of tracking verbal complaints. Using these forms is a way for the Nursing Home to keep track of the issues reported and to ensure appropriate follow-up. These concern forms are typically kept in file folders or digitally. Prior to a survey, Social Services should ensure these forms are organized and completed. Complaints that are not resolved should note steps that were taken and what the plan for completion would be. Surveyors often request these complaint forms when responding to resident concerns they hear while interviewing residents. Concern forms allow the Nursing Home to document that these concerns were recorded, and this is what has been done to resolve them. To understand the responsiveness of the facility staff, notes from Resident Council and other meetings will also be reviewed. The Social Services Director should be completing weekly audits ensuring assessments like BIMS and PHQ9's are completed on the schedule required, that clients' preferences are added to their chart, and that services demonstrate a person-centered approach, and that updated documents like releases of information are signed and uploaded, among other related tasks. For example, every resident living in a Nursing Home requires a PASRR (pre-admission screening and resident review program), prior to being admitted to a faciliity. These PASRRs require updates when certain criteria are met. Ensuring every resident has an up to date PASRR and that they are uploaded to their chart is an on-going task that will prepare the department for a survey. In preparation for surveys, Social Services departments can also review residents with mental health issues and ensure ongoing mental health supports are happening as required by the PASSR or other plans. This includes notes for these providers in resident charts, periodic case reviews with their mental health providers and offering additional supports that would be expected in their mental health care plan. Social Services departments should ensure weekly audits and compliance to ensure that upon survey day, they are ready. Surveys can happen at any moment, so it's best to be prepared. More in depth audits and compliance assurance can be completed before the beginning of the interval for the next annual survey.