Long-Term Care Survey Alert

Published on Mon Dec 23, 2013 PDF

HR experts suggest adapting systems to keep up.

New survey processes and unannounced survey schedules have changed the way some facilities audit their personnel files to prepare for review — or at least how they focus their efforts. Are you due for an update?

Centralize Data For Improved Access

One innovative approach is having a centralized information management system to audit files across departments on a continuous basis. Department managers can actively use the system to track everything from licensing to competency to occupational health tests for your health system employees.

The centralized, accessible database will give you some advantages in monitoring files and document deadlines and help the department managers to stay on top of audits.

Try this: Ensure that you have a new manager orientation where you talk to the new managers about the need to do a file audit initially to make sure that required items are there.

Make a special audit checklist. You can have a 90-day orientation department checklist that must be included. Do this for evaluations that are due, or TB tests that are due, and all other requirements. You can build into the system whatever you need.

Key: The HR department should ideally run audit reports on a quarterly basis. Ensure that whenever anyone is hired, all the information goes in. Audit all licenses on a rotating basis that you find feasible, and then the next month all certifications — include all the things that you need for The Joint Commission. Reviewing these items on a rotational basis every quarter ensures that you look at them regularly.

Focus On Key Components

File audits should cover the essential pieces and not attempt to incorporate everything. This will ensure that you not only get around to doing your file audit, but also that it works out just fine. If you find that you are a little behind in your HR filing, you might have to rush one day to get all your filing in order so that you can find everything.

Even though surveyors might ask for the entire personnel file, and not just items from a checklist, you need not prepare elaborately in the future. Instead concentrate only on making sure all the key components are complete and accessible.

Essentials: Key components include: Confirming that the performance appraisals are done, that employee health files show proof of TB and Hep B inoculation/vaccination has been done, and that competency files are easily located — for example, those maintained by department directors.

For new hires, the surveyors normally want to see the application, criminal background check and evidence of an interview, which is generally already in the employee files. If the HR department feels good about those components, they should not waste time doing a full-scale audit.

Select Experts For HR Interview Session

For new survey preparation, pay careful attention to the “Topics for Discussion” provided in the Survey Activity Guides (available on an accredited organization’s extranet site). Those involved in the review must be able to answer any of the evidence of compliance points.

Choose wisely: Anyone who will be present at the file review should be knowledgeable about where the documents are in the file. Also, make sure that individuals selected to participate in the HR interview session are the experts in the general and departmental orientation processes, know how competencies are determined at hire and ongoing, what efforts are underway to address diversity- and population-specific needs, including cultural and religious needs, and patient safety.

You might not really know whether or not to expect the checklist before a survey. Find out from your peers what surveyors have been asking and prepare accordingly. Implement a process at the department/unit level to maintain an education/competency file. Departmental educators should make sure staff update their required competencies. Then bring these files to the meeting with surveyors.

Try this: You can stay a step ahead by identifying in advance which items would likely be of interest to the surveyors by highlighting them with post-it notes. That way you will be able to pull the required documents. Just label them and carry them to the room for the surveyors to review.