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Survey Survival

May 1, 2005
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Are You Aware of These New Survey Requirements? by Reta A. Underwood, ADC
SURVEY survival

Are you aware of these new survey requirements? In the past few months we have encountered much "to do" regarding the changes in F-tag 314 Pressure Ulcers; however, little has been said regarding the State Operations Manual (SOM) Appendix PP-Guidance to Surveyors for Long Term Care Facilities, Revision 5, which was issued, became effective, and was implemented on November 19, 2004. One might think that this is because there wasn't much in it that was new, but such thinking is wrong. Not only was a tremendous amount changed, but serious ramifications await those facilities that do not review their own operational policies and procedures and take steps to update them to meet the new manual's expectations. My goal in this article is to give you the framework to be successful in meeting these new expectations.

What to Do First?
Because the new update involves all departments, you and your department directors must have a copy of the new SOM, and each nursing unit and supervisor should have a copy available for reference. Also, add a copy of the revised manual to the facility's library or survey binder to provide resident access to the changes, as required under revised resident rights in the new SOM.

It never ceases to amaze me just how far behind facilities can be in obtaining current, necessary information on operating under government regulation. As late as four months after its release, I was still coming across facilities that not only did not have this new version, but had key department staff who hadn't heard about the update. If you have not already downloaded your copy of the new SOM, visit

What Are the New Expectations?
Let's look at what revisions were made and how they may change the way you do things in your facility. An index for easy reference (but lacking mention of 493.25[d], the tags addressing bladder care and catheterization that are still under review [see my article "Preparing for CMS's Continence Care Revisions," ]) is included. Below are basic descriptions of the pertinent revisions and suggestions on possible operational adjustments needed.

Resident Rights 483.10(d)(2) F154.
Revision. Providers will need to show that a resident was informed in advance about care and treatment and of any changes in that care that may affect the resident's well-being. Interpretive guidelines have been added regarding the definition of what "informed in advance" means.

Tip. The facility should review and revise its policies and procedures on resident information, as needed, and provide staff education relative to these. Documentation should minimally cover points found within the interpretive guidelines. Also, be aware that the guidelines' revisions do not address what to do in cases in which the resident cannot comprehend the meaning of the care and treatment information. In long-term care, a general standard of practice is that the resident's responsible party/legal guardian be informed on the resident's behalf. Needless to say, the resident's or responsible party's feedback on the advanced care and treatment notice, carefully documented, will play an important part in determining facilities' compliance.

Notice of Rights and Services 483.10 (b)(1) F156.
Revision. It is stated clearly that residents are to be made aware of their legal rights and responsibilities and that the facility communicate these rights and responsibilities upon admission and at any time changes occur, in writing and in a language the resident can understand.

Tip. Resident rights materials can be purchased in alternate languages from a variety of resources or obtained free or for a minimal charge from your local state ombudsman. However, facility-specific policies or practices on residents' rights cannot, and providers must devise their own. Now is the time to adopt or update your resident handbooks in the languages that residents commonly speak in your facility. You may have to hire a translator (possibly a good community service project for your local college or high school, provided their work is reviewed by a credible resource). Abuse policies need to be updated regarding noncompliance with the advance directives requirements found in 483.10(b)(7) of this tag. Reviewing changes in abuse policies during a resident and/or family council meeting and having the minutes reflect this communication provides an additional opportunity. The facility's newsletter is also an avenue of positive marketing communication; take advantage of it. Regardless of the method of communication, make sure that resident rights and responsibilities and any changes made to them are governed by policies and procedures that staff understand and adhere to.

Privacy and Confidentiality 483.10(e) F164.
Revision. Storing, securing, and keeping confidential resident information in residents' records is the essence of the revision. The record should show the location of this confidential information (if not in the chart). It is not uncommon that social services keep confidential resident records in a location separate from the medical record, for example, but facility policy should govern this practice.

Tip. Review and revision of the facility's medical record confidentiality policy and procedures should be completed.

Accommodation of Needs 483.15(e) F246.