Environmental flags the surveyor won't miss.

Surveyors won't see anything you can't see - and do something about before the survey

Contrary to popular belief, most state surveyors are not strongly motivated to find deficiencies during their OBRA inspections - they just follow the path that the facility lays out for them. They start, not surprisingly, with past citations and the OSCAR reports, just to give them some initial direction. But then there are those environmental "flags" - so visible, so difficult to miss - they encounter simply by walking into a facility and looking around. What do they too often see? According to those responding to one of our firm's surveys, the five most frequently identified environmental problem areas are:

* Biological odor

* Floor care

* Infection control

* Safety standards 

* Resident condition

Let's take a brief look at each and why they occur - and, if you recognize your own facility in any of this, what you can do about it.

Biological odor. Marketing research supports the frequently stated perception that, if nursing homes smell, then they must provide substandard care. If facilities don't smell, quality care is assumed to exist. Surveyors may not go quite that far, but when they walk in the door and an odor hits them, they know where to look. If it's a stale smell, they look where toilets are sealed to the floor, and begin checking into maintenance. If it's a newer urine odor, the surveyors are going to look at resident care and housekeeping's attention to carpeting and upholstered furniture.

You can mask an odor with air freshener, but if air freshener is used, the surveyors are signalled to ask, "What are they covering?" The solution is to get rid of it by attending to resident care, housekeeping and maintenance to the extent that OBRA (and common sense) demands.

Floor Care. Conditions of the flooring, of course, leap out as among the first things noticed by a visiting surveyor, and they can send your facility down the slippery slope toward a deficiency. Look at your floor - does it have a hazy or grainy look, like a dirty floor waxed over? Are there stains or grout on the surface or, worse, evidence of recent spills? A surveyor seeing any of this will reasonably conclude that either housekeeping is not doing its job or residents aren't being monitored closely enough. These, too, are survey flags.

Infection Control. Surveyors look for rather obvious discrepancies in this area, and too often find them. How convenient, and used, are facilities for staff handwashing? Are gloves used when and where they should be? (A casual glance at the trash discloses whether it contains used gloves.) Are clean linens protected from contact with possibly contaminated surfaces, such as staff's uniforms? How much awareness does staff show in performing such basic procedures as dressing changes, connecting up for tube feedings, and sharps usage? What do you see right now in these areas? What do your quality assurance records and resident council minutes tell you about lingering problems or resident complaints?

Safety. In an intensive personal care facility such as a nursing home, there can easily be many accidents waiting to happen. Some of the surveyor flags would include: handrail availability and convenience; too much wetness and puddling in bathing areas; resident transfer equipment that looks poorly maintained or poses back injury hazards for staff; various carts, trash or laundry receptacles, or resident lifts blocking hallways; water temperatures that are too hot. These are easy to observe. Rectifying them before they are noticed takes some digging into the facility's equipment storage and maintenance routines, maintenance records, and schedules for resident transfer and meal delivery, as well as staff's observation of safety precautions.

Resident Condition. Surveyors make it a point of observing residents close-up and interacting with them directly. Your residents can scream out (sometimes literally) with cause for concern about deficiencies. This goes beyond residents' physical appearance - whether they appear dressed appropriately, clean and well-groomed - and goes to their interactions with staff and each other. Your social services and activities departments bear close scrutiny. Are residents' rights valued and observed? Are reasonable efforts made to involve them in activities appropriate to their level of function? What do residents and families think about this? You need to speak directly with them (just as a surveyor would) and, further, check into quality assurance and resident council records.

In general, when the surveyor sees someone who is not being taken care of in an acceptable manner and the facility has not documented that as a problem, this ranks number one on the deficiency list.

Historically, nursing homes have tended to be a reactive rather than proactive industry. Because of their intense regulatory environment, managers may develop the mindset: "We'll wait until we're cited on that," or "We don't really have to follow that rule because it's going to change anyway." Oddly enough, this is often an excuse for not trying harder.

Even though an active, ongoing quality assurance program would identify these problems, fewer than 10% of the facilities I have seen have a QA program that is working effectively. They lose sight of the fact that quality assurance is a dynamic process, and instead buy into the philosophy that it's just a compliance process generating a piece of paper. This is a hazardous stance to take, and not only from the viewpoint of OBRA.

Managed care is increasingly becoming a presence in long-term care, with its own ideas about accountability. As the managed care market becomes more competitive, it is a safe bet that most managed care organizations will demand a high level of quality assurance and of consistent performance. Managed care contracts will require accreditation and/or certification from various organizations - the Joint Commission, for example - for nursing facilities to have any hope of acquiring them. Facilities that can't keep pace won't get, or keep, contracts - it is as simple as that.

That is why being aware of the environmental flags and maintaining an active quality assurance program to address them will be crucial components not only to survey compliance, but facility survival.

Mary L. Taylor, NHA, RN, RS, Esq. is CEO of Taylor Consultants, based in Huntsville, OH, and has been involved in the long-term care industry for more than 25 years, some of those as an Ohio Department of Health surveyor and consultant for HCFA. For further information, 1-800-379-2833.