Beyond the survey checklist.

Findings from yet another report should continue to diminish our dependence on the current survey process and its questionable outcomes. After reading the report released by the Government Accountability Office (GAO) in December 2005 (Available at: www.gao.gov/new.items/d06117.pdf) one must ask, "Was my facility's survey really a success or was it a practical failure? What can be done to determine my facility's real state of quality compliance?"

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The GAO reports that CMS's nursing home survey data show a significant decrease in the number of nursing homes with serious problems, about 13% less. One would like to think this is because of an improvement in nursing home quality of care. However, the report indicates that this is not the reason. Rather, the report points to a lack of consistency in the survey process, as well as a tendency of state surveyors to cite serious deficiencies at a lesser level of harm than they should be. These findings are underscored by those federal resurveys of "same-state surveyed facilities" in which, according to the report, federal surveyors found and cited serious quality of care deficiencies, such as avoidable pressure sores, not cited by the state surveyors.

This issue has many twists and turns, but one must keep in mind that we are talking about compliance with minimum, not maximum, standards. Is it possible that the standard of care set by OBRA 15 years ago is so low that it actually hinders quality-related compliance and improvement? What if, instead of having a surveyor pinpointing a facility's noncompliance, the facility certifies compliance and spells out the reasons? Wouldn't this positive, active stance toward quality improvement bring about some change in management and resident care practices?

Let's take a closer look at the elements that might make this happen:

State-of-the-art service. Recognize the difference between antiquated practices and state-of-the-art service. Some of the "old ways," while not specifically prohibited in the State Operations Manual, are actually noncompliant delivery of care.

Do staff undress residents in their rooms before a shower and then transport them to the shower location wrapped in sheets and using a rolling shower chair? And do you still have residents sleeping on mattresses not rated for pressure relief? These actual examples I personally witnessed just this past month represent antiquated practices versus state-of-the-art service, and will most likely lead to a noncompliant status for you in the near future if not revamped. Don't fall victim to the trap of "we've always done it this way." Now is the time to transform the undignified shower experience into a beneficial spa-like treatment. And when replacing mattresses, settle for nothing less than mattresses designed specifically for pressure relief. "You'll find that the price is not a big difference and may actually save you money in the long run by preventing skin breakdown and related costs of litigation," says Loretta G. LeBar, Of Counsel for Stoll Keenon Ogden PLLC, Lexington, Kentucky, and former deputy attorney general for the state of Delaware, who today represents providers nationwide. "Furthermore, the RAI Coordinator may now note the intervention by marking Item M5b (SB-MDS 34b) 'skin treatments,' which is a feeder on the PPS RUG groupers for reimbursement. Thus, the end result allows both the resident and the facility to reap the benefits."

Direct observation. To truly know the status of things in your facility, you must get out of your office and become virtually part of the bedside staff. "You must be seen--regularly--on all shifts," says Kathy Corona, RN, C, director of nursing at Salina Presbyterian Manor in Salina, Kansas, a post she has held for the past 23 years. The facility has traditionally maintained not only a compliant status, but has been consistently deficiency-free. Including annual surveys, as well as a federal resurvey, it has received only one minor level deficiency in the past six years. Corona explains, "We don't let a yearly review determine how we're doing. I'm never in my office and I use checklists for everything and expect corrective feedback from my staff every day."

Additionally, says LeBar, "Every employee should know which areas of their responsibilities and job duties are particularly vulnerable to compliance challenges and lawsuits."

Data review. It is my opinion that the Facility Characteristics Report, the Facility Quality Indicator Profile Report, and the Resident Level Quality Indicator Summary Report--all based on facility-specific MDS data and available to all facilities on CMS's Medicare Data Communications Network site--should be part of the facility's ongoing quality assurance and improvement program. I further believe that without them, efforts toward improvement are for nil. These reports identify in detail which residents may cause surveyors to flag deficient facility practices, as well as those residents who may be expected to have special-care needs. Staff should also have a say, LeBar adds: "We must let employees who do the job participate in identifying areas of danger that are inherent in the delivery of services. Risk managers can no longer approach risk in a cookie-cutter fashion. Every facility is different, and employees need to have the opportunity to participate in the identification of issues that are unique to their facility."

Consumer feedback. Nothing even comes close to judging customer service more accurately than direct consumer feedback. While there are many ways to get this type of compliance perspective, one in particular is gaining popularity: the mystery shopper. Used in the restaurant and retail industries for years, providers and paying long-term care consumers are just realizing the benefits and potential of mystery shoppers. Because mystery shoppers simulate real-life experiences to gain access to and critique the facilities they visit, employees and residents alike feel less threatened by scrutiny and often communicate valuable information that would otherwise go unreported. (Mystery shopping can also be used by facilities to gauge the competition.) Mystery shopping can take on many forms and uses, including telephone calls, requests for informational materials, Web site reviews, on-site visits, or any combination thereof.

Put into effect, these four elements would deinstitutionalize services and make way for such quality-of-life innovations as the daily chef's special, all-private suites, therapeutic spa experiences, employee programs emphasizing profession and career as a norm, and more. All facilities would reap the rewards of not only being in survey compliance, but being in a profitable and satisfying business meeting real needs. And more administrators will be able to echo Kathy Corona when she says, "I love what I do."

Reta A. Underwood, ADC, is President of Consultants for Long Term Care, Inc., Louisville, Kentucky. For more information, call [phone] or visit www.cltcinc.com. To send your comments to the author and editors, please e-mail [e-mail].

BY RETA A. UNDERWOOD, ADC