Leslie Mahoney, RN, BSN, CEO, SAVVY on the SOM

A recent issue of McKnight’s Daily Update featured guest blogger Derek Pierce, the Managing Director of Healthcare Management Partners, raising 11 questions that facility operators should ask about surviving in the current market.

Question number 3 stood out for med: What is the star rating of the skilled nursing facility? And how did the most recent state survey go?

The SNF star rating provides a quick test of quality and is ultimately what consumers will look at when they are assessing your facility. From a risk perspective, it is important to understand and evaluate any deficiencies noted in the state survey. Compliance is not only important from a marketing perspective, but a failure to meet requirements can be critical to a facility’s very survival, and rightly so.

As a former surveyor, I frequently found that administrators and even directors of nursing had very little understanding of the complexity of the regulations in the State Operations Manual (SOM). When discussing deficiencies with the facility staff, they were frequently unaware of the specific requirements of a regulation that the facility had failed to meet. For example, in one facility, cooking unpasteurized eggs as “over easy” and not checking the temperature led to Immediate Jeopardy. The cook and the facility consultant seemed unaware of the regulation.

I frequently found medical directors and pharmacists who were also completely unaware of the regulatory requirements for their involvement in ensuring that current standards of practice for infection control were followed (F-501 and F-881 for the medical director) and in oversight of antibiotic ordering (F-756 Drug Regimen Review , F-757 for Unnecessary Drugs and F-881 for Pharmacists).

Conversely, I found that the administrators of the 4- and 5-star facilities could practically quote the SOM regulation by regulation. The SOM had become their Bible.

My observations were not unique to me. Other surveyors I worked with had the same observations and concerns. We were all perplexed as to why some administrators didn’t seem to use their SOM as a tool to help them with regulatory compliance and as a resource when writing policies. All the while consistently complaining about over regulation.

When I asked administrators to actually produce their SOM, I got answers like “it’s around here somewhere.” It was also often pulled off of the shelf, covered in dust. I was always shocked and wondered: Why was this happening? I finally decided to do some investigating.

I began calling universities that offer master’s of health administration degrees and asked for a copy of their syllabus. I studied their offerings for a single class on Medicare regulations. The best I could find was a class on JCAHO regulations. I then called counselors and raised my concern about their curriculum. They suggested understanding the Medicare regulations was done during the Administrator in Training experience.

The AITs I have spoken with during surveys were most often working on special projects such as marketing, resident satisfaction, or analysis of budget and revenue.

So, my question is still unanswered. Actually maybe this query bears the implementation of the six questions of investigating or project management — who, what, where, when, why and how. Who needs training in the regulations, what would that look like, where should it take place and when, and how, can we make sure that it happens. The why is all too obvious.

I raise these questions in the hopes they will start a discussion on the use of the SOM by administrators and DONs. Until the SOM becomes the quintessential tool for regulatory compliance, a 5-star rating will be out of reach. And rightly so.

Leslie Mahoney, RN, BSN was a SNF surveyor for the California Department of Public Health. She is currently the founder and CEO of SAVVY on the SOM, an online subscription newsletter focused on the clinical implementation of the SNF regulations, a clinical consultant and a hospice triage nurse.