Do Health Surveys Actually Improve Nursing Homes?

With a tip of the hat to Charles Dickens, it was a very bad day, and then it became the unimaginably worst day ever. It was the day I went to work and saw the sign on the door announcing "Facility Being Surveyed by the Department of Health." I was a social service director at a large nursing home and this was the signal that our annual survey had begun. I was not looking forward to it.

As I was settling in, getting my mind prepared for what was sure to be a grueling week, a co-worker came into my office and asked, "Have you heard the news?"

I sighed, "Yes, we are in survey." Looking puzzled he replied, "No, the World Trade Center has been hit by terrorists." Now I was puzzled, as I hadn't listened to the news that morning. He re-iterated the bad news, and then I realized that not only were surveyors in the building, but our country had just been attacked. Yes, the date was 9-11-2001.

Thus began a horrible week, both for the nursing home staff and for the country as a whole. Although the surveyors were employees with the State of California, and all state employees had been ordered to go home, these inspectors did not. They chose to continue with their surveying tasks, and were with us for the entire week.

This created an almost impossible situation. The staff had to attend to the needs of the surveyors, which involved finding the documentation they requested, answering questions about the care the residents received, and monitoring the facility to ensure all staff were following protocol. In addition we were trying to deal with our own feelings and grief issues, especially as several of the staff knew people who worked in the World Trade Center. At the same time we were trying to keep the residents calm, and assist them with processing their feelings. Some of the WW II veterans were trying to figure out how they could re-enlist!

The Purpose of Inspections
Skilled nursing homes that accept Medicare and Medicaid funds are inspected at least yearly to ensure that the facility is compliant with regulatory codes. The Center for Medicare & Medicaid Services (CMS) is the part of the US Department of Health and Human Services that oversees the Medicare and Medicaid programs. CMS then contracts with each state to provide the on-site inspections. The inspections are usually unannounced, although most nursing homes know when they are due, and have been gearing up for months in order to be ready. Inspections can also occur randomly, especially if a nursing home has a history of poor inspections. The state inspectors also respond to complaints.

The survey team usually consists of 4-5 inspectors, usually registered nurses, but may also include a dietician, social worker, or pharmacist. A fire safety specialist also conducts an inspection, although this may occur at a different time.

What is the Process?
Upon arriving at the facility, the survey team will post signs around the building to inform the public that a survey is in process. Family members or residents are encouraged to report any concerns they may have. It was this sign that tipped me off that my nursing home had started the process. The first task of the inspectors is to do a walk-through of the facility. This involves walking from room to room, gathering information about each resident. They also look for any obvious problems.

After the walk-through, the surveyors will retire to a designated room to prepare their approach. Each nursing home is required to submit quarterly documentation electronically to the state, called a Minimum Data Set. The team has already reviewed these reports and has identified the residents that they want to review. They have also targeted major concerns, i.e. the facility has a high rate of falls.

During this initial phase, the staff are busy gathering documents that the surveyors require, such as suspected abuse logs, staffing schedules, demographic reports with the ages of residents, how many wear hearing aids, glasses, etc. While trying to complete this task, we tried to ignore the news reports of the tragedy that the residents had playing on the televisions in their rooms.

There are over 150 regulatory standards that nursing homes must meet, which cover all aspects of resident life. They include but are not limited to: safe storage and preparation of food, medication administration, resident rights, nursing care, clean environment, activities, and social services. In addition to reviewing the clinical record, the inspectors will interview family and residents, observe nursing care being provided, meals being fed, and on-going activities. They will watch to see if call lights are being answered in a timely manner, often timing them with a stopwatch.

They will also look for discrepancies or omissions in the written documentation. A plan of care might state that a resident will be bathed twice a week. The inspectors check the nursing flow sheets to see if this is documented. If there is no documentation, it is considered to have never happened, even if the resident states, "I always get my bath." On the other hand, a resident may claim they never get a bath, yet the documentation can indicate that showers are given as scheduled. In this case, the surveyor might consider that the documentation has been falsified.

Upon completion of the survey, the facility is notified of any problems, or deficiencies. Most nursing homes have at least a few deficiencies, although a few nursing homes can brag about a zero deficiency survey. The nursing home then must prepare a plan of correction to ensure that all of these problems are corrected, and take steps ensure it does not happen again.

You can find out how a facility did on their last survey by going to Medicare.gov, Nursing Home Compare. This will bring up a list of the deficiencies of any facility you are interested in. When I checked my previous facility, they had 13 health deficiencies and 4 safety deficiencies in the last survey. This was about average for the state.

This information must be viewed selectively, however. Unless you are privy to the details of the situation, it can be difficult to determine just how serious it is. Yes, there are bad nursing homes out there, and they do tend to score very poorly on a survey. But most nursing home administrators and staff genuinely care about the quality of care they provide, and try every day to do their best. Mistakes do happen, and staffing can often be a challenge, but my experience is that for the most part, residents of nursing homes get very good care.

Do Surveys Help Improve Nursing Homes?
Which leads me back to the title of this article. Do health surveys contribute to the improvement of the nursing home, or do they actually make it harder to do a good job? From the point of view of the caregivers, too much time is spent documenting what we were doing, and too little time actually doing it. In other words, the volume of documentation required to ensure a successful survey has become so cumbersome, it actually adversely affects the quality of the care.

Let me give you an example. As a social worker, I was expected to visit residents who, for one reason or another, seldom left their rooms. The care plan might indicate that this was to be done 2-3 times a week. The purpose was to provide socialization, and to ensure that their psychosocial needs were being met. Let's say that I visited Mrs. Brown who was bed-ridden. She complained to me that the nurses were not giving her the pain medication that had been ordered. Mrs. Brown would also call a family member and complain and he would call me. I would then check with the charge nurse who stated that the medication was given as ordered by the doctor, but that Mrs. Brown would often forget that she had received it.

The total time to visit this resident and talk to her family member might be 15-30 minutes. Follow-up time with the nurse could add another 5-10 minutes, more if I checked the medication record myself. To ensure that this information was communicated to a surveyor, I would make a note in the chart about the room visit and my follow-up. I would also indicate that this resident had a history of claiming she didn't get her medication. I might choose to administer a mini-mental exam to document that she did indeed demonstrate short-term memory loss. This assessment tool could take up to 30-45 minutes. I would update the plan of care, identifying the psychosocial issue and provide interventions. One example could be providing a notepad for resident to sign when she received her medication, both to remind her it was given, and to provide further documentation to the family member.

Multiply this scenario times 100, depending on the size of the nursing home, and you can see how documenting can quickly eat up your time. Yet without this on-going record, it would be difficult to show an inspector that the facility was aware of the resident's concerns and had intervened. In addition to the social services intervention, nursing would document that they had reported to complaint to the doctor, in case he wanted to change medication. They would do a pain assessment, and indicate on the nursing care plans what comfort measures had been tried. The activity staff would also document their room visits as well and possibly provide music therapy to distract the resident from her pain.

How Much is Enough?
When I left the industry in August of 2006, CMS had just initiated a new Psychosocial Severity Guide. This new guideline focuses on the decline in a resident's psychosocial well-being due to the facility's non-compliance of any regulation. The result was a flurry of new assessments tools mandated by the corporate office to counteract any claims by inspectors that these issues were not being addressed. I estimated that implementing the new paperwork for a new admission would take a minimum of 1-½ hours, and we had an average of 20 admissions a week. At the time, I had one full-time assistant.

Those of us who went into the helping professions, such as nurses, social workers, activity professionals, and dieticians, did so with the expectation that we would be helping people. We believed in the importance of personal contact and providing support to people in need. People who are admitted to nursing homes are often at a stage of life where they have lost family, friends, belongings, and are now moving from a home environment to an institution. This transition often is difficult and people need a lot of one-on-one attention.

But with the requirements placed upon facilities to comply with Federal regulations, more and more time is spent on documentation, planning and preparing for survey, doing chart reviews to ensure that all the components have been entered into the medical record, and doing walk-arounds to make sure other people are doing their jobs. There is very little chance of actually spending any quality time with a resident. This creates a rebound effect, for the less one-on-one time a resident receives, the greater the chance that it will adversely affect their psychosocial well-being, which in turn leads to survey deficiencies.

There is a place for Health Department surveys, especially to weed out the very poorly run homes that never seem to improve. But the current process subjects even well run nursing homes to a meaningless and overly subjective scrutiny. It forces a company to develop an even longer paperwork trail to meet these requirements. In the final analysis, it is a disservice to the people we are trying to serve, the nursing home resident.

Sources:

Website: Medicare.gov, Nursing Home Compare
http://www.medicare.gov/NHCompare

Website: The American Medical Directors Association
http://www.amda.com/publications/hpa/june2006/Psychosocial_Outcome.cfm

Website: US Dept of Health and Human Services
The Official US Government Site for People with Medicare
http://www.medicare.gov/nursing/aboutinspections.asp

Website: Center for Medicare and Medicaid Services, US Dept of Health and Human Services
http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp