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July 2007

Is Your Long-Term Care Facility Survey-Ready? Operational Guidelines, Policies and Procedures

Long-term care facilities know the importance of survey preparation and the deficiencies, fines and negative publicity that can come with poor results. Facilities are also aware that year-round survey readiness leads to deficiency-free surveys.

The most current and complete operational policy and procedure manuals are at the core of survey readiness. The daily operation of a nursing home, continuing care retirement community (CCRC), assisted living facility or other long-term care institution not only involves the provision of direct care to residents but also includes anything from public relations to laundry distribution. Operational guidelines, policies and procedures must be written to validate why the facility has implemented protocols in all these areas.

If deficiencies occur during a survey, the administration of the facility is required to complete a written Plan of Correction explaining how and when the non-compliance will be corrected. A good Plan of Correction is expected to clearly state the problem, set specific goals to solve the problem, identify trends and patterns, look at root causes and monitor progress.

According to the State Operations Manual, Survey Procedures for Long-Term Care Facilities, §7304, CMS, May 2004, an acceptable Plan of Correction must:

• Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice
  
• Address how the facility will identify other residents having the potential to be affected by the same deficient practice
  
• Indicate how the facility plans to monitor its performance to ensure solutions are sustained. 

This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The Plan of Correction is integrated into the quality assurance program, and it includes the dates when corrective action will be completed.

If the facility is cited for deficiencies involving operational guidelines, policies and/or procedures, the following should be considered:

1. Examine the facility operational guidelines/policies/procedures related to the practices.

• Are they clear, specific and based on current professional standards and guidelines of practice?
  
• Are they readily available to staff members?
  
• Are all staff members familiar with them?
  
• Do staff members need in-services about the guidelines?
  
• Does the policy/procedure need to be rewritten or updated?

    2.   Evaluate the actual staff practices in the facility.

• Are staff members following the policy and procedure as it is written in the manual?
  
• Do the staff members need counseling or training?
  
• Are managers adequately monitoring staff practices?

As you can see, complete, up-to-date policies and procedures are essential to writing an acceptable Plan of Correction.  However, more importantly, the facility should have these policies and procedures in place before the need for a Plan of Correction arises. 

Policy and procedure manuals should be user friendly, and they are best presented in three-ring binders that simplify updating. The manuals must be organized, easy to read and understand, consistent, readily accessible to all staff and reviewed annually for changes or updates. Click here for more information on Briggs Resident Care Policy and Procedures.

During a survey, directors and staff should be prepared to show how these documents guide the behavior of nursing home staff and ultimately improve resident care. For more information on Briggs Survey products, click here.

When the facility consistently reviews/updates their operational and policy/procedures manuals, they are less likely to incur deficiencies at survey time. Click here for more information on Briggs Operational Guidelines.

Sandra Kay Scott (Webb), RN, BS
Webb Enterprises

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