Tips on preparing for surveys

James McLain
James McLain

When it comes to preparing for state survey inspections, an ounce of prevention is worth a pound of paperwork. Every month we receive frantic calls from facility managers who are scrambling to develop a plan of correction in response to one or more deficiencies from a recent state survey. Handrails that are deemed unsafe or have fallen into disrepair, doors and frames that do not meet fire and Life Safety Codes, or privacy curtains that are missing or improperly installed.

The Centers for Medicare & Medicaid Services believes each of these items (along with all the other surveyed elements) either directly or indirectly impact the safety, well-being and quality of life of the eldercare resident. For this reason CMS has moved towards providing full disclosure on the results of state surveys at Medicare.gov where family members and care providers can see survey results in real-time (search Nursing Home Compare). This potential for negative publicity can make attracting new residents and maintaining high occupancy rates an even greater challenge in a hypercompetitive market.

But there is a silver lining.  While the main focus of the survey elevates privacy, dietary, pharmacy, nursing and other acute areas of resident concern, make no mistake: Facility and housekeeping deficiencies matter. The good news is that many (if not most) of these items can easily and affordably be addressed before the inspection happens. It all comes down to having knowledge and awareness of how the process works, then taking proactive steps. Facilities that do this will dramatically reduce their odds of being cited on a facility-related deficiency.  

For nearly two decades Construction Specialties has offered information and guidance to our clients on how they can proactively prepare for their next survey and even pass it with flying colors. Our goal is to encourage and equip facility and housekeeping managers to take a few minutes to perform a brief, preventative survey of these commonly overlooked items before the survey team arrives unexpectedly on their doorstep. Preparation resources for state surveys are also available from online resources such as those found at cms.gov and nursinghomehelp.com.

It comes down to how being forewarned can lead to being forearmed. For this reason, we developed an informative Survey Preparation Checklist to help facility managers address three common areas inspectors look at closely during state surveys. Each of these areas are found among the myriad of CMS F-tags and Life Safety Code K-tags that are associated with the survey protocols.

One of the required survey inspection items are the facility's handrails. F-468 requires that most eldercare facilities be equipped with firmly secured handrails on each side of the hallways and corridors. Generally, handrails don't draw too much attention, but be certain the inspectors will be taking a close look in this instance.  

Facility managers should inspect handrails for sharp edges, splinters or potential tear points for skin.  Check for peeling or worn finishes that could become sources for bacterial growth, especially on older, wooden rails. Look for loose fitting or unsafe handrails while inspecting the brackets for a snug, tight fit to the wall. Replace non-compliant handrails that have less than the required 1½ inch ADA grip surface.  Do these things and you will dramatically reduce your odds of being cited for an F-468 deficiency.

Privacy curtains are another area where a simple checklist can prevent costly and time consuming write-ups. F-460 requires that full visual privacy be provided in multiple-occupancy rooms, with each resident having a curtain suspended from the ceiling that extends around the bed to adjacent walls and curtains. For best practices, facility and housekeeping staff should ensure all such areas have compliant curtains with mesh and fully functioning track mechanisms.  

Privacy curtains must also comply with Life Safety Codes K074 and K150 which affect the above floor finish height of the curtain for cleaning, and clearance of the mesh below the ceiling for air exchange and fire sprinklers. Curtains must be installed to NFPA-13 standards and be constructed of fire retardant materials and properly tagged in compliance with NFPA-701 requirements.

All curtains should be laundered regularly, especially between resident room changes.  CS introduced several convenient design features like Snap-Lock and On the Right Track to reduce the time and labor needed to switch-out curtains, making this a simple task. Also, we recommend having plenty of additional curtains in stock, laundered and ready for action.

Doors present their own challenges. Life Safety Codes K018 and K021-028 have very strict requirements for the thickness of the door, its material composition, space tolerances between the floor, and most importantly, the fire rating. Most doors must be capable of resisting smoke and fire for 20 minutes, but local fire and building codes must also be considered for varying door locations and conditions.  Facility maintenance or housekeeping should check all such doors for proper fire rating labels and tags, which are commonly found on the hinge side or top of most doors.  

At the end of the day, most potential survey citations can be easily prevented and remedied before it's too late. Often, the solutions are designed to save you time and money while minimizing the hassle of dealing with survey violations. Consider purchasing products from service providers who understand the requirements of CMS, who truly know and speak the language, to ensure you are ready and equipped to pass your next state survey.  Ask if they have a survey preparation checklist for their products to ensure all details are addressed. Doing this will make an ounce of prevention seem like a very light burden, indeed.

Jim McLain has worked in the eldercare industry for 16 years as the General Manager Construction Specialties Eldercare Interiors Division, the manufacturer of Acrovyn® interior products. He can be reached at jmclain@c-sgroup.com or 262-827-3090 to discuss ways to prepare for a future state survey.

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