Long-Term Care Survey Alert

Published on Sun Nov 18, 2007 PDF

Don't let false beliefs cause your facility grief.

Survey-related myths tend to persist until they butt heads with reality in a painful clash of F tags. Below, experts provide a roundup of some of the most common misperceptions they've seen in the survey world.

1. A facility can only be decertified for immediate jeopardy. Not so, says Joseph Bianculli, an attorney in private practice in Arlington, VA. A D-level deficiency alone will do the trick after six months of noncompliance.

Every deficiency "D" or above triggers a maximum 180-day termination track, he explains. And the facility has to be back in substantial compliance at some point within 180 days from the original survey resulting in deficiencies.

2. The amount of a civil monetary penalty is tied only to the seriousness of a deficiency. That's true, in part, says Bianculli, but the total amount is determined by the duration of the noncompliance, including retroactive noncompliance, he points out. And the facility is out of compliance until the state survey agency or the Centers for Medicare & Medicaid Services determines that it's back in compliance. That means facilities need clear documentation of their corrective actions, he advises.

3. Care plans should be pages and pages long to pass muster with surveyors. If you don't streamline and focus on the resident's true risks and problems, you'll end up with a novel-length care plan that no one can follow, including surveyors.

Instead: Facilities should care plan a resident's identified risks based on a risk assessment -- "not every remote potential for a risk," says Diana Waugh, RN, BSN, principal of Waugh Consulting in Waterville, OH.

Example: If the resident has never had a pressure ulcer, can move independently in bed, has good nutrition and hydration and has a low-risk score on standardized risk assessments for skin breakdown, etc., "you wouldn't care plan that issue," says Waugh.

A corollary myth: Some providers think you prepare care plans for surveyors. That's a belief that Waugh encounters often. She was, in fact, recently working with a facility that had gotten in some survey trouble, in part, over their care plans. Staff had finished a full assessment with RAPs and care planning on the first of the month but had no new care plan in place 17 days later. When Waugh asked the MDS nurse about the care plan, she answered, "Oh yes, we have done that -- it's in my office."

Reality check: The care plan should be accessible and regularly directing the resident's care, says Waugh -- and in a "language that the CNAs can easily understand."

4. A surveyor who doesn't follow the survey protocol or behaves rudely invalidates the survey findings. There's a "specific regulation that says that [surveyors'] failure to follow proper procedures most definitely does not affect otherwise valid findings," says Bianculli.

5. The survey process is "personal." That's the most prevalent misconception that attorney Christopher Lucas encounters -- one that he thinks can create bad feelings that jeopardize a facility's survey outcomes.

Providers who view survey findings as a "reflection of their own personal self-worth are setting themselves up for disappointment and, ultimately, burnout," warns Lucas, who's in private practice in Mechanicsburg, PA. And the survey team may sense the provider's hostility, which can cause the survey team to become less objective in evaluating the facility, in Lucas' view.

Knowledge is power: Learn the regs better than surveyors, Waugh suggests. "Read them and ... when surveyors have a different interpretation, then you can begin a dialogue, saying, 'This is how I read them, and I think I am in compliance because I'm doing x, y and z.'" If surveyors cite you anyway, you can use the IDR process -- "and you've done your homework already."

Providers also have false beliefs about the informal dispute resolution process, notes Bianculli. For one, some believe that an IDR extends the time for filing an appeal. But the regulations and manual guidance clearly state that it does not, he says.

Another mistaken idea: CMS has to accept a favorable IDR result. "In fact, CMS makes clear that it doesn't have to," says Bianculli.

In Maryland, survey agency chief Wendy Kronmiller tells Long-Term Care Survey Alert that she encounters providers who believe they can't use bedrails at all, which isn't true. "In our state, facilities can use bedrails if they have followed the RAI manual protocol and care planned use of the siderails."