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Decrease survey deficiencies: An educational intervention

February 1, 2011
by Timothy J. Legg, PhD, CNHA, GNP-BC, FACHCA, Deborah Adelman, PhD, RN, NE-BC, CNS, and Sharon A. Nazarchuk, PhD, MHA, RN
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Teaching nursing staff about long-term care rules and regulations improves survey results

Failure to maintain compliance with applicable rules and regulations can be costly to skilled nursing facilities (SNFs). The Office of Inspector General (OIG) reported that approximately $81.7 million were charged in civil money penalties during 2001.1 In 2008, the major deficiencies received by SNFs most relevant to nursing services included: accident prevention (44%), quality of care (33%), comprehensive care plans (26%), pressure ulcer prevention/treatment (21%), and unnecessary drugs (21%).2

It is well known that the number of deficiencies in SNFs is increasing. Trends from 2005 to 2007 demonstrated a 9.5% increase in the total number of deficiencies given to SNFs during the survey process. As of 2007, 91.9% of all nursing homes had received deficiencies.3 Skilled nursing facility owner/operators must take every step within their means to ensure that residents receive care and services consistent with applicable rules and regulations. In this article, we describe a case study of an educational intervention that was undertaken in an effort to reduce survey deficiencies.


Many factors impact deficiencies received during the survey process. For example, it is known that lower RN and LPN staffing levels result in more deficiencies related to nursing care.4 It is also known that care of the older adult is covered minimally (if not missing entirely) in most nursing education programs. With the exception of basic nursing skills, nursing education programs teach students nothing about the nuances of nursing care in the SNF.5-7

Timothy J. Legg, PhD, CNHA, GNP-BC, FACHCA
Timothy J. Legg, PhD, CNHA, GNP-BC, FACHCA

What remains to be explored is whether providing nurses who work in skilled nursing facilities with additional education specific to gerontological nursing concepts and SNF regulatory requirements can impact the number or scope and severity of deficiencies received during annual or abbreviated surveys.


Deborah Adelman, PhD, RN, NE-BC, CNS
Deborah Adelman, PhD, RN, NE-BC, CNS

In an effort to reduce deficiencies that might be the result of nurses lacking knowledge of gerontological nursing concepts as well as SNF rules and regulations, we developed a program in conjunction with a board-certified gerontological nurse practitioner and a licensed nursing home administrator. The program consisted of 24 hours of instruction delivered over the course of three days. A complete outline of the topics included can be found in Table 1.

Sharon A. Nazarchuk, PhD, MHA, RN
Sharon A. Nazarchuk, PhD, MHA, RN

How would we know if the program worked? Our team examined survey deficiencies for the two years preceding the delivery of the educational program then monitored the facility for two years afterward. A six-month period of time separated both two-year periods while the educational programs were being delivered. Permission to conduct this study was obtained by the appropriate institutional review boards and governing body of the SNF. The program was delivered to a 185-bed Medicare-/Medicaid-certified Pennsylvania-based SNF that participated in the program.

Who attended the training? The educational program consisted of three 8-hour sessions delivered to RNs and LPNs employed in the SNF where the case study took place. For a staff member to be included in the training, he or she had to be employed for a minimum of six months to ensure that the individual had completed general orientation, unit/shift orientation where they would be scheduled, and completion of the probationary period. A total of 38 nurses (30 LPNs and 8 RNs) completed the three-day training provided over a six-month period. In the two years following the training, four of the RNs and 15 LPNs in the program left the organization (50% turnover).

Staff members received their regular pay rate and were excused from all floor duties during each day of training. Nursing staff's attendance at the training program was mandated by the facility's administrator. The same instructor provided training for all sessions to minimize variation in instructional technique and variations in presentation of content.


Total number of deficiencies. The actual number of deficiencies received during annual or abbreviated (complaint) surveys for the two-year period before the educational program was provided and then for the two-year period after the program was completed.

Scope and severity of deficiency and description of deficient practice. This measure was selected to determine whether the intervention had any impact on the number of deficiencies or the scope and severity of any deficiencies received, particularly in those areas that were covered in the training sessions. This was how we attempted to determine whether teaching on the topic would have an impact on deficiencies received.