MDS Alert

Published on Mon May 30, 2016 PDF

Why the QIS tools should be your basis for a mock survey.

Managers are on the floor scrutinizing everyone and everything. Nursing staff are nervously trying to remember the answers to potential surveyor questions. You know what time it is: It’s annual survey time.

But preparing for a visit from surveyors doesn’t always have to be a nail-biting, white-knuckled experience. Here are some tips to make the survey preparation experience a little less stressful for all facility staff:

Make Survey Prep a Year-Round Event

Best bet: One of the best things your facility can do to prepare for the annual survey is to never stop preparing, says Kris Mastrangelo, President and CEO of Harmony Healthcare International. Don’t wait until you’re getting back “into the window” to kick into gear.

You should be “survey ready” all the time, agreed Kay Hashagen, PT, MBA, RAC-CT of LW Consulting Inc. in a recent presentation for the Pennsylvania Coalition of Affiliated Healthcare & Living Communities. You also need to make sure you fixed any deficiencies that occurred previously and know what the surveyors are looking for.

Rule of thumb: “All of the things that you implemented to prepare for the survey/revisit should have sustainable systems in place, that only require refinements,” Mastrangelo stresses.

Revisit Your Last Survey’s POC

Still, you can take this opportunity to revisit your last survey’s Plans of Correction (POCs), Mastrangelo notes. Validate that you’re still in compliance with those identified areas.

Be sure to educate your staff on areas where deficiencies occurred in the past, Hashagen instructed. “Make sure that you are diligent in the details so that future surveys are spot-on.”

Strategy: A good idea for managers is to walk rounds with an eye out for potential safety hazards and dignity tags, Mastrangelo advises. Dining room rounds are valuable as well.

Use the QIS Tools

Foundation: You should also use the Quality Indicator Survey (QIS) tools as a basis for a mock survey, according to Mastrangelo. “They are excellent tools for an informal mock audit of a targeted area (like the dining room) and can also be used to do an official facility mock survey.” And incorporate areas of concern into your facility’s Quality Assurance Performance Improvement (QAPI) process.

Make sure your QAPI process is up and running, Hashagen advised. Use your QAPI “to support any deficiencies that you had in the past. Figure out if there is a hole in your current process.”

Get Outside Help

You can use an impartial outside entity to perform the mock survey. “Too often, risk areas are overlooked not because of lack of knowledge, but because of proximity,” Mastrangelo explains. “Skilled professionals within a facility can overlook issues. Mock surveys should be done by people not directly working in the facility, for objectivity.”

If you decided to work with an outside entity to conduct a mock survey, you should have an entrance meeting and exit meeting, Mastrangelo says. You should “go through the process prioritizing based upon QM triggers and review of accident reports, environmental rounds, and general observations.”

Tip: Another strategy is to implement audits between disciplines to identify errors, Hashagen offered. “It’s hard to see your own mistakes, [but] easy for others to spot.”

Resources: You can find the QIS tools at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/QIS-Survey-Forms.html. Use the QIS survey forms for your mock survey.