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Survey Preparedness and Management



A solid survey preparedness and management system is pivotal for Quality and Compliance. When surveyors enter a facility, it is ideal for facilities to assemble and have an organized and accurate survey binder and a knowledgeable staff that understand their role during the Survey. This will indicate to surveyors that the facility is always alert, aware, prepared, and ready to begin the survey process.

The ongoing auditing of Systems such as, “High Risk” care and service areas associated with significant risk to health and safety (e.g., Abuse, Falls, the development of Pressure Injuries, Infections, the administration of high-risk medications, (insulin, opioids, antibiotics, etc.) “High Volume” care and service areas (e.g., medication administration, laboratory testing, transcription of orders, resident care, safety and environmental checks, nursing documentation), and finally “Adverse Events” which is an untoward, unanticipated event that causes death or serious injury, or the risk thereof, including near misses, (e.g., falls with major injury, (fracture), opioid overdose, elopement, disasters, fires, infectious disease outbreaks, will identify opportunities for improvement, communication, and system enhancement to position the facility for a successful outcome. This Strategic auditing must be developed, implemented, maintained through the facilities Comprehensive, Data-driven QAPI Program.

Below is what I call the must KNOW’s for a Survey Victory:

  • KNOW the Federal and State Regulations and Interpretive guidelines.

  • KNOW how the Surveyors will conduct the Survey Process.

  • KNOW what information Surveyors will request at Entrance, within an hour, within 4 hours, etc.

  • KNOW Best Practices for when Surveyors enter the building.

  • KNOW your facility and staff during Routine and Emergency Operations.

  • KNOW and use the Surveyors Tools and Resources for facility Audits.

  • KNOW how to respond to Potential and Actual Deficiencies (e.g., Immediate Jeopardy, conducting and writing a Plan of Correction, etc.)

For questions or additional assistance needed, please contact Patricia Manchester: pmanchester@covenanthealthnetwork.org